Every finding on record at Bay Pointe Nursing Pavilion

Based on observation and interviews, the facility failed to ensure hand hygiene was offered to residents before dining, staff performed hand hygiene during meal tray passing, and infection control standards of practice were followed in the kitchen. Findings included:On 7/7/26 at 9:25 a.m., an observation of the dish machine area revealed Staff O, Dietary Aide and Staff P, Dietary Aide, operating the dish machine. Both staff were observed with painted, artificial fingernails approximately one half inch to one inch long. Staff P was observed scraping dirty kitchenware before loading the items into the dish machine. Staff P then demonstrated how she checked the sanitizing solution and temperature of the dish machine but did not perform hand hygiene before touching testing strips and clean dishware. On 7/7/26 at 9:37 a.m., an observation of a rack containing clean and dry pans and other kitchenware showed a cell phone belonging to Staff R, Cook, placed on the rack among the clean items. On 7/7/26 at 12:11 p.m., an observation showed multiple residents waiting in the main dining room for lunch to be served. At 12:34 p.m., staff began passing meal trays; no residents were offered hand hygiene before beginning their meals. On 7/7/26 at 12:35 p.m., Staff Q, Certified Nursing Assistant (CNA), was observed entering the dining room and assisting with passing meal trays without performing hand hygiene. At 12:37 p.m., Staff Q touched the handles of a resident's wheelchair and escorted the resident out of the dining room. Staff Q returned, touched his mouth and adjusted his glasses, then resumed passing meal trays without performing hand hygiene. On 7/9/26 at 11:15 a.m., an interview was conducted with residents who regularly attended resident council meetings. The residents stated staff did not offer hand hygiene, such as sanitizing wipes or hand sanitizer, before meals. Some stated they used the bathroom in their rooms to wash their hands. On 7/9/26 at 1:54 p.m., an interview was conducted with the Food Service Manager (FSM). The FSM stated kitchen staff were not permitted to have painted or artificial fingernails because they could harbor bacteria or chip into food. She stated she had noticed the kitchen staff's fingernails herself. She stated the staff member scraping dishes should have removed gloves and washed hands before checking the dish machine sanitizing solution. She stated staff must wash their hands when transitioning from handling dirty items to clean items. She stated personal items, including cell phones, were not permitted in the kitchen and should be stored in a designated area away from food preparation. On 7/9/26 at 4:08 p.m., an interview was conducted with Staff B, Registered Nurse/Unit Manager (RN/UM). Staff B stated staff were expected to assist residents with washing their hands or offering hand sanitizer before meals, whether they ate in their rooms or the dining room. She stated staff should perform hand hygiene between passing meal trays to each resident. On 7/10/26 at 11:05 a.m., an interview was conducted with the Director of Nursing (DON)/Infection Preventionist (IP). She stated the facility did not have a process for offering hand hygiene to residents before meals. She stated she participated in educating kitchen staff on infection prevention and said her expectation was for staff fingernails to be short and clean. She stated long nails increased the risk of contamination. She stated personal items should not be in the kitchen because they posed a risk of spreading illness. A review of the facility's policy titled Hand Washing and Glove Use, dated 6/2026, revealed the following, Hand washing plays a vital role in infection control, reducing the surface microorganisms on our hands. Gloves are used to provide a barrier between potential microorganisms and ready-to-eat food items being prepared and/or portioned by staff. Further review of the policy, under procedure, revealed the following, 1. Hands must be washed prior to beginning work, after using the restroom, after smoking, when working with different food sources, following contact with unsanitary surfaces, and before wearing gloves. A review of the facility's policy titled Personal Hygiene, dated 6/2026, revealed the following, To ensure proper personal hygiene practices to prevent contamination of food. Further review of the policy, under procedure, revealed the following, .5. Keep fingernails short, clean and without fingernail polish or nail jewelry. A review of the facility's policy titled Hand Hygiene, dated 10/2021, revealed the following, The facility considers hand hygiene the primary means to prevent the spread of infections. Further review of the policy, under procedure, revealed the following, .2. Personnel shall follow the hand washing forward/ hand hygiene guidelines to prevent the spread of infections to other personnel, residents, and visitors.5. Employees must wash their hands for twenty (20) seconds using antimicrobial or non-antimicrobial soap and water under the following conditions: . Before and after assisting a resident with meals (hand washing with soap and water) . After blowing or wiping nose; . After performing your personal hygiene (hand washing with soap and water); .

Based on record review and interviews, the facility failed to update required Level I Preadmission Screening and Resident Review (PASARR) information and failed to complete Level II PASRR evaluations when needed. This failure affected four (Residents #17, #4, #6, and #80) out of 21 residents sampled. As a result, these residents did not receive required assessments to determine whether they needed specialized mental health services. Findings include: Record review showed Resident #17 was first admitted on [DATE] with several mental health diagnoses, including Brief Psychotic Disorder, Major Depressive Disorder (recurrent, moderate), and Generalized Anxiety Disorder. A review of the resident's PASARR Level I screening dated 04/17/2024 showed only Psychotic Disorder marked as a qualifying mental health diagnosis. Further review showed the resident was given new diagnoses of Major Depressive Disorder (recurrent, moderate) and Generalized Anxiety Disorder on 05/01/2026. The facility did not complete a Level II PASARR evaluation after these diagnoses were added. Record review showed Resident #4 was admitted on [DATE] and re admitted on [DATE]. Diagnoses included altered mental status, bipolar disorder with psychotic features, generalized anxiety disorder, Alzheimer's disease, depression, and post traumatic stress disorder. Review of the PASARR dated 08/15/2026 showed only bipolar disorder marked for mental illness or suspected mental illness. None of the other mental health diagnoses were listed on the form as required. Record review showed Resident #6 was admitted on [DATE] and re admitted on [DATE]. Diagnoses included Major Depressive Disorder (recurrent, moderate), Generalized Anxiety Disorder, and Anxiety Disorder (unspecified). Physician orders showed the resident was prescribed escitalopram for depression. A review of the resident's PASARR Level I screening dated 07/24/2024 showed no mental illness diagnoses marked, even though the resident had documented mental health conditions. Record review showed Resident #80 was admitted on [DATE] and re admitted on [DATE]. Diagnoses included bipolar disorder with psychotic features, dementia, psychotic and mood disturbances, anxiety, major depressive disorder (recurrent), and epilepsy. The resident's physician orders included medications used to treat schizophrenia, bipolar disorder with psychotic features, and seizures. The care plan showed the resident used psychotropic medications for anxiety, depression, neuropathy, and bipolar disorder with psychotic features. Review of the PASARR Level I dated 12/31/2024 showed several mental health diagnoses marked; however, the form also stated, No diagnosis or suspicion of Serious Mental Illness or Intellectual Disability indicated. Level II PASARR evaluation not required. The facility did not provide documentation showing that they submitted materials for a required Level II PASARR evaluation. During an interview conducted on 07/10/2026 at 11:06 a.m., the Director of Nursing (DON) and the Regional Nurse Consultant (RNC) stated the Social Services Director gained access to the state PASARR vendor website only the day before. The DON stated they did not have login access to submit PASARR Level I or Level II evaluations when they began their role in May 2026, and no staff at the facility had access to the system. They stated the facility was still working on gaining access. A review of the facility's policy titled PASRR – Requirements for Completion, dated 08/2025, showed the facility was required to determine if a resident had a serious mental illness, and if a Level II evaluation was triggered, to submit required documents to the state vendor in a timely manner so that the Level II could be completed within required time frames.

Based on observations, interviews, and record review, the facility failed to ensure medications were stored according to professional standards for three of six medication carts reviewed and failed to ensure medications were not stored at the bedside. This deficient practice created the potential for medication contamination, diversion, and unsafe administration. Findings include: On [DATE] at 10:00 a.m., an observation of Resident #24 showed a medication cup containing two pills—one peach colored and one red—left on the resident's bedside table. On [DATE] at 8:50 a.m., an observation of the 100 Hall medication cart showed a container of bleach kill wipes stored directly next to resident medication cards in the bottom drawer with no divider separating the chemicals from the medications. The same observation showed a Trelegy [medication for asthma] inhaler in the cart without an opened or expiration date marked, although manufacturer instructions required discarding the inhaler 42 days after opening. On [DATE] at 10:20 a.m., an observation of the 200 Hall medication cart showed an opened vial of Lispro insulin with an expiration date of [DATE] and an opened vial of Glargine insulin with an expiration date of [DATE]. An interview on [DATE] at 10:31 A.M. with Staff M, Licensed Practical Nurse (LPN) was conducted. Staff M, LPN verified both insulin vials were expired and stated they should have been discarded. On [DATE] at 11:36 a.m., an observation of the locked narcotic drawer of the 500 Hall medication cart showed 28 syringes of Lorazepam [anti-anxiety medication] Gel 1 mg/ml that expired on [DATE]. An interview on [DATE] at 1:30 p.m., with the Director of Nursing (DON) was conducted. The DON stated bleach wipes should not have been stored next to medication cards. She stated the facility did not have enough dividers for the medication carts and stated she was unaware expired Lorazepam syringes were in the narcotic drawer. She stated nurses were expected to stay with residents until all medications were consumed and that the facility did not have any residents who could self administer medications. An interview on [DATE] at 1:35 p.m., with the Regional Nurse Consultant (RNC) was conducted. The RNC stated both insulin vials were expired and stated nurses were responsible for cleaning out the medication carts. She confirmed nurses were expected to remain with residents until medications were administered. On [DATE] at 10:47 a.m., an observation of Resident #110's dresser showed a nebulizer device with a mask attached. The resident stated he used the nebulizer every so often. An additional observation showed a small clear vial containing liquid on the dresser; the resident stated it was medicine for his breathing treatment and that he sometimes administered it himself. On [DATE] at 10:04 a.m., another observation of Resident #110's room showed an oblong white pill with M367 imprinted on it on the floor under the dresser. The resident stated it was his pain pill. A clear plastic medication cup was also found on the floor near the dresser. Record review showed Resident #110 was admitted on [DATE] with diagnoses including chronic obstructive pulmonary disease with acute exacerbation, respiratory failure, and malignant neoplasm of the lung. Physician orders included Hydrocodone Acetaminophen Tablet 10 325 mg, one tablet every six hours for severe pain, and Ipratropium Albuterol Solution 3 ml via nebulizer four times a day for shortness of breath. Record review showed no physician orders authorizing the resident to self administer medications or treatments. A review of Resident #110's medication administration record (MAR) and treatment administration record (TAR) showed nebulizer treatments were documented daily by nursing staff in June and [DATE], except on [DATE], which was documented as drug refused. A review of Resident #110's care plan revealed the following: - ALTERED RESPIRATORY STATUS: The resident has altered respiratory status/Difficulty Breathing r/t COPD (chronic obstructive pulmonary disease), SOB [shortness of breath], meds [medications] as prescribed, with interventions to include, Administer medication/puffers as ordered. Monitor for effectiveness and side effects. On [DATE] at 11:05 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). Staff G stated no resident in her assignment could self administer medications or treatments and stated a physician order was required for self administration. She stated Resident #110 did not administer his own nebulizer treatment or medications. On [DATE] at 3:58 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated no resident in the facility was authorized to self administer medications or treatments. She stated Resident #110 did not administer his own medications and stated the nebulizer and medication observed at the bedside on [DATE] should not have been present. A review of the facility's policy titled Medication Administration General Guidelines, dated 1/2026, revealed the following, Medications are administered as prescribed in accordance with manufacturers' specifications, good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. Further review of the policy revealed the following, .Medication Administration: . 5. The person who prepares the dose for administration is the person who administers the dose. 15. Residents are allowed to self-administer medications when specifically authorized by the prescriber, the nursing care center's Interdisciplinary Team (IDT), and in accordance with procedures for self-administration of medications and state regulations. (Refer to Section 7.3 — Self-Administration By Resident) . 20. The resident is always observed after administration to ensure that the dose was completely ingested. If only a partial dose is ingested, this is noted on the MAR, and action is taken as appropriate. A review of an undated policy titled, Medication Storage – Storage of Medication revealed the policy was medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration. The procedure 9: Potentially harmful substances (such as urine test reagent tablets, household poisons, cleaning supplies, disinfectants) are clearly identified and stored in an area separate from medications; 14: Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .and reordered from pharmacy.

Based on observation, record review, and interviews, the facility did not ensure dignity was maintained for one (Resident #12) out of 44 sampled residents, as the resident was observed wearing the same clothing items on three of four days. This practice did not support the resident's dignity. Findings included:On 7/7/26 at 2:55 p.m., Resident #12 was observed lying in bed wearing a royal blue collared shirt and flannel pants with a black and red plaid pattern. On 7/8/26 at 10:00 a.m., Resident #12 was observed lying in bed wearing the same shirt and pants observed on July 7, 2026. On 7/10/26 at 9:49 a.m., Resident #12 was observed wearing the same shirt and pants observed on July 7 and July 8, 2026. A review of Resident #12's admission record showed an initial admission on [DATE], and readmission on [DATE]. Diagnoses included lack of coordination, muscle wasting and atrophy affecting multiple sites, and a need for assistance with personal care. A review of Resident #12's care plan revealed the following focus areas:- COGNITION: The resident has impaired cognitive function/dementia or impaired thought processes r/t [related to] Moderately Impaired: Bims Score 8-12 Date Initiated: 02/20/2026.- ADL [activities of daily living]: The Resident has an ADL Self Care Performance Deficit . Date Initiated: 02/04/2026 Revision on: 02/05/2026, with interventions to include, DRESSING: Assist of 1. Upper- Supervision or touching assistance Lower-Supervision or touching assistance Footwear-Supervision or touching assistance Date Initiated: 02/04/2026.- BEHAVIORAL: The resident is noted with the following behaviors: Refuses Dialysis, Dm [diabetes mellitus] meds [medications] and other meds and POC [plan of care] at times. Turns tube feed pump on/off at times Date Initiated: 04/13/2026 Revision on: 06/24/2026. A review of Resident #12's minimum data set (MDS) quarterly assessment, dated 6/4/26, revealed, a brief interview for mental status (BIMS) score of 10, indicating moderately impaired cognition. Resident #12's functional abilities, revealed resident requires supervision or touching assistance for upper and lower body dressing. A review of Resident #12's progress notes from June 2026 to July 2026 showed no documentation of Resident #12 expressing a preference to wear the same clothing daily, no documentation of refusals to change clothes, and no entries regarding missing clothing items. A review of Resident #12's inventory sheet, dated May 6, 2026, listed three t shirts of assorted colors, one pair of red shoes, three basketball shorts, three pairs of white socks, one bible, two stuffed animals, and one prosthetic leg. A review of the grievance log from February 2026 through July 2026 showed no documented grievances from Resident #12 related to missing clothing items. On 7/10/26 at 9:52 a.m., an interview was conducted with Staff A, Certified Nursing Assistant (CNA). Staff A, said the resident can put his shirt on and requires assistance with lower body dressing. She confirmed Resident #12 did not have many clothing items because the resident's family took clothing home to wash and staff were not certain how often items were returned. She stated she recalled a family member reporting missing clothing items. An observation of the resident's closet conducted with Staff A showed no clothing items present. On 7/10/26 at 10:01 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager (UM). Staff B, said Resident #12 had additional clothing items besides those worn but stated the resident did not have many garments. She added that washed items might be in the laundry room and sometimes took a few days to be returned. On 7/10/26 at 10:29 a.m., an interview was conducted with the Housekeeping/Laundry Manager and Staff C, Housekeeping/Laundry aide. Staff C, Housekeeping/Laundry aide said the nursing staff brought the items that needed to be laundered in a bag, and the resident's name should be inside the bag. Staff C said nursing staff are informed and encouraged to bring the residents' personal items to the laundry room directly, instead of taking it to the soiled bin. The Housekeeping/Laundry Manager said when they washed personal items, to include clothes, they were returned to the resident on the same day. Staff C, Housekeeping/Laundry aide, stated the resident's clothing items might be in the soiled bin and would need to be checked. On 7/10/26 at 11:03 a.m., an interview was conducted with the Director of Nursing (DON). She said if a resident did not have clothes in their closet, they should go to laundry to check. If a residents' clothes were not in the laundry room, she expected them to find clothing items in their size from the donation bin. She said she also expected the staff to call family members if needed. She said the resident should wear a gown until they receive their clothes. The DON said she expected the CNA to offer to change the residents' clothes if they were wearing the same clothing the day before. She said if the resident refused, she expected there to be documentation. A policy related to dignity and ADLs was requested but not provided by the facility. A review of the facility's policy titled Resident Rights, dated 8/2025, revealed the following, The facility strives to ensure that each resident has a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility. The facility will protect and promote the rights of each resident. Further review of the policy, under procedure, revealed the following, .3. Intervene with staff, residents, and / or family members as necessary regarding complaints and / or grievances. a. [NAME] differences, problems, or issues as they arise or are referred to the department period. 4. Assist the resident representative with missing items.

Based on observation, record review and interviews, the facility failed to ensure nail care, to include cleaning and trimming, was provided to one (Resident #80) out of five residents reviewed for activities of daily living (ADLs). Findings include: On 7/7/26 at 10:34 a.m., an observation of Resident #80 was conducted. The resident was lying in bed. An observation of both hands showed several fingernails that were approximately one half inch to one inch long, with dark colored debris underneath them. Resident #80 stated he wanted his fingernails trimmed and said they had been trimmed while he lived at the facility; however, he could not recall when this last occurred. Record review showed Resident #80 was admitted on [DATE] and re admitted on [DATE]. Diagnoses included lack of coordination, generalized muscle weakness, muscle wasting and atrophy, need for assistance with personal care, contracture of the left hand, and type 2 diabetes mellitus. A review of Resident #80's care plan showed an ADL Self Care Performance Deficit, initiated on 12/24/2025 and revised on 01/15/2026, with interventions including PERSONAL HYGIENE: Supervision or touching assistance, initiated on 01/22/2026 and revised on 06/10/2026. Review of the care plan also showed a Behavioral section documenting potential verbally abusive behaviors, with no entries indicating refusal of nail care or personal hygiene. A review of Resident #80's progress notes from June 2026 to July 2026 revealed no documentation showing the resident refused nail care or personal hygiene. A review of the shower schedule showed Resident #80 was scheduled for showers on Mondays and Thursdays during the 3:00 p.m. to 11:00 p.m. shift. The schedule included instructions stating, . If patient refuses, your nurse is to be notified and a second attempt is to be made. If patient continues to refuse then the refusal is to be documented on the shower sheet. A review of Resident #80's shower sheets from June 2026 through July 2026 showed the following: On 6/4/26, 6/29/26, and 7/2/26, Nails Trimmed was marked as not completed with no documentation of refusal. On 6/11/26 and 6/18/26, the shower sheets showed the resident refused nail care. On 6/9/26, 6/15/26, 6/21/26, 6/22/26, and 6/25/26, no documentation was entered for Nails Trimmed. On 7/8/26 at 10:28 a.m., an interview was conducted with Staff E, Certified Nursing Assistant (CNA). Staff E stated an activities staff member usually cleaned and trimmed residents' nails, but that staff member was not present that day. She said CNAs were also responsible for cleaning and trimming nails and documented refusals in the Kardex, which she identified as the electronic documentation system. Staff E viewed Resident #80's fingernails during the interview and confirmed they appeared the same as during the prior day's observation. Staff E stated Resident #80 did not like having his nails cut. She asked the resident if he wanted his nails cut that day, and he stated he was okay with it. Staff E stated she had documented when Resident #80 refused nail care. On 7/9/26 at 9:20 a.m., an interview was conducted with Staff F, Central Supply/Medical Records/CNA. Staff F stated she used the shower book to determine when residents in her assignment were scheduled for showers. She stated CNAs were expected to communicate with residents about shower preferences, notify the nurse if a resident refused, document refusals in the electronic record, and attempt again later in the shift. Staff F stated shower refusals were documented in an alert in the Kardex system rather than in the task itself. She stated CNAs were supposed to complete shower sheets, although this did not always occur. Staff F stated nail care was completed by activities staff on certain days. She stated the facility did not have nail clippers but had nail files and sticks to clean under fingernails. She stated CNAs could also perform nail care, but the responsibility often fell to activities staff. She confirmed nail care was included as an as needed task in the Kardex. On 7/9/26 at 3:32 p.m., an interview was conducted with Staff B, Registered Nurse/Unit Manager (RN/UM), and the Director of Nursing (DON). The DON stated staff were expected to use shower sheets and document shower and nail care completion in shower sheets, progress notes, and CNA tasks. Staff B stated CNAs should complete nail care as part of daily grooming and stated she cut residents' nails if needed. Both staff stated refusals should be documented on the shower sheet. Staff B stated Resident #80 should have his nails cleaned and trimmed during his scheduled showers. The DON confirmed nail care should occur during showers and as needed and stated Resident #80 frequently refused nail care. She stated documentation of his refusals should appear on the shower sheet. A policy related to ADLs or nail care was requested but was not provided.

Based on observations, record review, and interviews, the facility failed to follow physician orders for elevation of the head of the bed (HOB) during enteral nutrition administration for one (Resident #8) out of four residents sampled for tube feeding. As a result, Resident #8 received enteral nutrition while lying below the required elevation level, increasing the risk of aspiration. Findings include:On 7/7/26 at 11:00 a.m., an observation of Resident #8 showed a bottle of [nutritional supplement] 1.5 infusing at 45 milliliters per hour. The resident's head of bed was slightly elevated at less than the required 30 to 45 degrees. On 7/8/26 at 10:16 a.m., an additional observation showed Resident #8 receiving [nutritional supplement] 1.5 at 45 milliliters per hour with the head of bed elevated less than the required 30 to 45 degrees. On 7/9/26 at 11:08 a.m., an observation revealed Resident #8 receiving [nutritional supplement] 1.5 at 45 milliliters per hour while lying nearly flat, with little to no elevation of the head of the bed. Record review showed Resident #8 was admitted on [DATE] and re admitted on [DATE]. Diagnoses included hemiplegia and hemiparesis following cerebral infarction affecting the right dominant side, type 2 diabetes mellitus without complications, oropharyngeal dysphagia, gastrostomy status, gastro esophageal reflux disease, and adult failure to thrive. Record review showed physician orders directing: NPO [nothing by mouth] diet NPO texture, NPO consistency. Additional physician orders directed: every shift Enteral Feed: [nutritional supplement] 1.5 Cal Continuous via tube to infuse at a rate of 45 mL/hr. Total volume of 900 ml infused in 24 H. May turn off for care/services. Start at 2pm. Verify infusing every shift. Clear pump when total volume has infused. AND in the afternoon Enteral Feed: [nutritional supplement] 1.5 Cal Continuous via tube to infuse at a rate of 45 mL/hr. Total volume of 900 ml infused in 24 H. May turn off for care/services. Start at 2pm. Verify infusing every shift. Clear pump when total volume has infused. Physician orders also directed: Elevate head of bed while feeding and medication is being administered every shift for Prevention. Record review showed the care plan included a Tube Feeding problem documenting enteral feeding with interventions including: Elevate HOB 30 45 degrees during administration of feeding or medication administration. A review of [NAME] Nutrition Health Institute's (ANHI) guide to adult tube feeding (the manufacturer of the tube feeding formula Resident #8 received), revealed the following, . Administering your feedings . Do not lie flat during your feeding. Keep your head raised at 30 degrees or more while administering your tube feeding. (website accessed: https://www.anhi.org/content/dam/an/anhi/pdf/guide-to-adult-tube-feeding-at-home-final-pdf.pdf) On 7/9/26 at 11:06 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). She said the nursing staff would elevate or position the HOB during administration of a resident's tube feeding. She said the HOB should be elevated to 45 degrees when a resident is receiving the tube feeding. On 7/9/26 at 1:38 p.m., an interview was conducted with Staff N, Registered Dietitian (RD). Staff N, Registered Dietitian (RD), stated the head of bed should be elevated during enteral nutrition administration to reduce the risk of aspiration. On 7/9/26 at 4:06 p.m., an interview was conducted with Staff B, Registered Nurse (RN)/Unit Manager (UM) and the Director of Nursing (DON). Staff B, RN/UM said when a resident was receiving EN the HOB should be at a 45-degree angle. She said the HOB might be lowered if the resident could do it themselves or if the Certified Nursing Assistant (CNA) moved it. Staff B, RN/UM and DON confirmed Resident #8 would not be able to adjust or move the HOB elevation. They both said the 45-degree elevation was a, Standard, for any resident with a percutaneous endoscopic gastrostomy (PEG) tube, tracheostomy, and/or chronic obstructive pulmonary disease (COPD). A review of the facility's policy titled Nutrition - Enteral/Parenteral Nutrition & [and] Hydration, dated 10/2021, revealed the following, Enteral/Parenteral nutrition and hydration palliative care will focus on the resident/patient's enjoyment, relief of symptoms, and maintenance of energy and strength. Optimizing nutritional status to delay decline will be an appropriate goal only if in accordance with resident/patient or legal guardian's wish.

Based on observation, record review, and interviews, the facility failed to follow physician orders related to oxygen therapy for one resident (#110) out of two residents reviewed for respiratory care. This failure resulted in Resident #110 not receiving oxygen as ordered. Findings include:On 7/7/26 at 10:46 a.m., an observation and interview were conducted with Resident #110. Resident #110 stated he was supposed to have oxygen on, but reported the oxygen machine was placed in his roommate's area. Observation of the room showed an oxygen concentrator was located on the other side of the privacy curtain near the B bed and was not in use. On 7/8/26 at 10:04 a.m., observation showed the same condition: the oxygen concentrator remained at the B bed and was not being used by Resident #110. Record review showed Resident #110 was admitted on [DATE]. Diagnoses included chronic obstructive pulmonary disease with acute exacerbation, respiratory failure (unspecified), respiratory disorders related to other diseases, and malignant neoplasm of the bronchus or lung. Record review showed a physician order dated 2/25/26 directing: Oxygen at 2L [liters] PM [per minute] Via [by] nasal canula continuously for SOB [shortness of breath] to maintain oxygen saturation 92% every shift for Shortness of Breath. Record review showed Resident #110's care plan included an Oxygen Therapy problem stating, The resident has Oxygen Therapy r/t [related to] COPD [chronic obstructive pulmonary disease] Does not always wear 02 [oxygen] as prescribed, with interventions including: Administer Oxygen as ordered. (Refer to current POS/MAR for current order) Give medications as ordered by physician. Monitor/document side effects and effectiveness . The care plan also included an Altered Respiratory Status problem stating, The resident has altered respiratory status/Difficulty Breathing r/t COPD, SOB, meds as prescribed, with the intervention, Oxygen as ordered. A review of Resident #110's medication administration record (MAR) and treatment administration record (TAR) showed oxygen was documented as administered daily in June 2026 except on 6/28/26, with no associated progress note. In July 2026, oxygen was documented as administered daily except on 7/2/26 and 7/8/26, with no associated progress notes. Record reviews showed progress notes from May through July 2026 contained no documentation of Resident #110 refusing oxygen or removing his nasal cannula. On 7/9/26 at 11:05 a.m., an interview was conducted with Staff G, Licensed Practical Nurse (LPN). Staff G stated Resident #110 was supposed to have oxygen administered but stated he often took it off. Staff G reported the current oxygen orders were as needed, and stated there was no documentation showing when Resident #110 removed his oxygen. Record review did not show an as needed oxygen order and instead showed a continuous oxygen order. On 7/9/26 at 3:58 p.m., an interview was conducted with the Director of Nursing (DON). The DON stated Resident #110 had continuous oxygen orders. She stated the resident would need an as needed order if he did not require continuous oxygen and his oxygen saturation levels were normal. The DON stated staff should document No on the MAR/TAR if the resident was not using oxygen as ordered. Record review of the facility's policy titled Oxygen Therapy, dated 8/2025, showed the policy stated, Oxygen is provided to residents based on physician's orders to supplement oxygen as needed per disease process.

Based on observations, record reviews, and staff interviews, the facility failed to follow up on recommended dental services for one (Resident #68) out of eight residents sampled. Findings included:On 07/07/2026 at 4:31 p.m., and interview and observation of Resident #68 occurred. Resident #68 was observed sitting in his wheelchair in his room. Resident #68 stated he had asked the facility for assistance obtaining lower dentures, but no one had followed up on his request. Review of Resident 68's Resident Information Record dated 04/29/2026 showed Resident # 68 was admitted on [DATE] with diagnoses including unspecified sequelae of cerebral infarction, muscle wasting and atrophy of multiple sites, type 2 diabetes mellitus with hyperglycemia, and need for assistance with personal care. Record review showed a Minimum Data Set (MDS), dated [DATE], which documented a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. Record review of a Dental Services Report dated 05/20/2026 showed Resident #68 was screened by the dental provider. The report documented that Resident #68 was interested in a new denture and partial, pending approval, and stated Office will follow up for approval. On 07/10/2026 at 9:00 a.m., an interview was conducted with the Social Services Director (SSD). The SSD stated that when a resident or nurse requests dental services, she faxes a referral to the dental provider. She stated she was aware Resident #68 had missing teeth but was not aware he wanted dentures because she did not read the screening report. She stated she receives the dentist's screening reports but does not review them; instead, she places the reports in the resident's chart and marks in the system that the resident was seen. She stated she does not follow up on recommendations documented by the dentist. She stated she did not follow up regarding Resident #68's request for dentures. On 07/10/2026 at 9:00 a.m., an interview was conducted with the Regional Nurse Consultant. The Regional Nurse Consultant stated that when a resident is seen by the dentist, the Social Services Director is expected to review the dental documentation and forward a copy to the Director of Nursing so the dentist's recommendations can be reviewed and appropriately followed up. Record review of the facility's policy titled Scope of Service, dated 02/2021, showed the policy required the facility to provide an adequate number of staff to meet residents' medically related social service needs. The policy included: Assist other staff or make appropriate referrals to identify unmet needs which may potentially have a negative effect on the resident/patient's physical, mental and psychosocial well-being, such as, but not limited to dental/denture care.

Based on interviews and record review, the facility did not ensure required discharge information was documented for one (Resident #117) out of one closed record reviewed. As a result, the resident's discharge record was incomplete and did not contain required documentation for an Against Medical Advice (AMA) discharge. Findings include:Record review showed Resident #117 was admitted on [DATE], and discharged on April 11, 2026. Further review of progress notes showed there was no documentation that Resident #117 left the facility Against Medical Advice (AMA) or that the physician was notified of the discharge. Review of the electronic health record and the paper chart showed there was no AMA discharge form for Resident #117. During an interview conducted on July 8, 2026, at 5:01 p.m., the Nursing Home Administrator (NHA) stated that Resident #117 left AMA. The NHA stated the documents included in the paper chart were all of the documentation the facility had for Resident #117. He stated there should have been an AMA discharge form, but he could not locate the form. The NHA stated that if a resident left AMA, staff should document the discharge in the progress notes. During an interview conducted on July 9, 2026, at 2:02 p.m., the Social Services Director (SSD) and the Director of Nursing (DON). The SSD stated that when a resident leaves AMA, the physician is notified, an AMA discharge form is completed and signed by the resident or resident representative, and the Department of Family and Children Services (DCF) is notified to request a welfare check. She stated she would document this information in the progress notes. The DON stated that if Resident #117 left AMA, an AMA discharge form should have been in the resident's chart. She stated she was not sure if Resident #117 had an AMA form in the file. An AMA discharge form for Resident #117 was requested but was not provided by the facility at the time of the survey. Review of the facility's policy titled Discharge/Leave Against Medical Advice (AMA), dated February 2026, showed the policy required staff to complete a Discharge Against Medical Advice form when a cognitively intact resident insisted on leaving AMA. The policy required notification of the physician to obtain AMA orders, obtaining the resident's signature on the form, notifying the attending physician, Administrator, and DON of the resident's request to leave AMA, and documenting Discharge AMA with the reason in the nurses' notes.

Based on observations, record reviews and interviews the facility failed to ensure shift to shift controlled substance logs were complete and accurate for five hall logs (100, 300, 400, 500, and 600) out of six controlled substance logs reviewed. Findings included: On 4/8/26 at 9:12 a.m. during an observation, interview and narcotic count verification of the 400 Hall even cart with Staff A, Licensed Practical Nurse (LPN), the controlled substance key exchange audit (CSKEA)form used to document controlled medications and medication cart key exchange was noted blank. There were no signatures by the off going or oncoming nurse. Staff A, LPN said controlled medications were counted at the beginning of the shift and stated she did not sign the form. Staff A, LPN was also assigned to the 300 Hall cart, and the CSKEA form was not signed. Staff A, LPN was observed signing the oncoming nurse column. On 4/8/26 at 9:51 a.m. during an observation, interview and narcotic count verification of the 400 Hall odd and 500 Hall carts with Staff B, Registered Nurse (RN). Staff B, RN had signed the CSKEA form for the count with the oncoming 3:00 p.m. to11:00 p.m. nurse. In response to when the form should be signed, Staff B, RN said I should sign at the end of my shift, my mistake, I should not have done that.On 4/8/26 at 9:57 a.m. during an observation, interview and narcotic count verification of the 100 Hall even and 600 Hall carts with Staff C, LPN. The CSKEA forms were not signed at the beginning of the shift. Staff C, LPN said the count had been completed and she forgot to sign the form. During the count verification for the 600 Hall medication cart Staff C, LPN said there were 40 cards, but 41 cards were present during the verification count. In response to the discrepancy, Staff C, LPN said she received a controlled medication card on 4/7/26 and forgot to add it to the log. An observation of the bubble packs found 8 punctured, torn or taped packs on the 100 Hall even cart and 2 on the 600 Hall cart. Staff C, LPN said she checks the bubble packs for tampering during the narcotic count. In reference to non-intact bubble package, she said it does not appear to be tampered with because, the pills are in there.On 4/8/26 at 10:37 a.m. during an observation, interview and narcotic count verification of the 100 Hall odd and 200 Hall carts with Staff D, RN, she said the CSKEA on both carts were not signed because the count was interrupted by a resident emergency. Staff D, RN was observed signing the oncoming nurse column on both logs. On 4/8/26 at 2:25 p.m. during an interview with Staff E, LPN, Unit Manager (UM) said during shift change the nurses are expected to count controlled medications and both nurses sign the CSKEA form. Staff E said the nurses should observe front and back of the bubble packs to make sure the packaging was intact. She said the pills should not be secured by tape. Staff E stated if the bubble pack was not intact, two nurses are expected to waste the medication.On 4/8/26 at 3:32 p.m. during a telephone interview, the Medial Director (MD) said controlled substance counts must be accurate, and nurses are expected to follow the facility's protocol. The MD said if a bubble pack appears to be tampered with, the nurse is required to follow the established protocol.On 4/8/26 at 3:39 p.m. during a telephone interview, the facility pharmacy services pharmacist said bubble packets that are not intact should be logged and reported to the Director of Nursing (DON). The pharmacist said prior to transporting controlled medications, the cards are checked to make sure they have not been tampered with.On 4/8/26 at 11:00 a.m. during an interview the DON said the oncoming and off going nurses are expected to sign the controlled medication key exchange form when the count is completed. The DON stated the medications should be stored in packages that are not damaged. She said if the bubble packs were not intact, two nurses are expected to waste the medication. On 4/8/26 at 5:21 p.m. the DON said each time the key for controlled medications storage drawer is transferred between nurses, the medication cart log requires dual nurse verification at each shift change, including signatures from both the off-going and oncoming nurse, as well as documented verification of the total number of medication cards in the cart. The DON said this process ensures accountability, accuracy, and continuity of care and should be completed. She said new employees are instructed on how to document the use of controlled medications by the orienting nurse. The DON said the medication cart log requires dual nurse verification at each shift change, including signatures from both the off-going and oncoming nurse, as well as documented verification of the total number of medication cards in the cart.A review of March 2026 controlled drug-key exchange audit forms the facility provided showed the following: 100 Hall-Opportunities 86-Missing Signatures (Count) 23-% Missing Signatures 26.7%-Missing Card Count Documentation (Count) 3-% Missing Card Count 3.4% 300 Hall-Opportunities reviewed 67-Missing Signatures (Count) 26-% Missing Signatures 38.8%-Missing Card Count Documentation (Count) 3-% Missing Card Count 4.5% 500 Hall --Opportunities 84-Missing Signatures (Count) 19-% Missing Signatures 22.6-Missing Card Count Documentation (Count) 15-% Missing Card Count 17.9% 600 Hall-Opportunities 82-Missing Signatures (Count)15-% Missing Signatures 18.3%-Missing Card Count Documentation (Count) 9-% Missing Card Count 11.0 %A review of facility policy titled Controlled Medication Storage, dated 1/26, revealed the following: Policy- Medications included in the Drug Enforcement Administration (DEA) or state classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations.5. A controlled medication accountability record is prepared when receiving inventory of any controlled substance to establish a record of receipt and disposition in sufficient detail to enable accurate reconciliation .14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .A review of facility policy titled Controlled Substances, dated 1/26 revealed the following: Policy-'Controlled Medications are substances that have an accepted medical use (medications which fall under U.S. Drug Enforcement Agency (DEA) Schedules Il-V), have a potential for abuse, ranging from low to high, and may also lead to physical or psychological dependence. These medications are subject to special handling, storage, disposal, and record keeping at the nursing care center, in accordance with federal and state laws and regulations.Procedures: 2. The Director of Nursing and the Consultant Pharmacist establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled.7. At each shift change, a physical inventory of controlled medications, as defined by state/federal regulations, is conducted and is documented on an audit record.8. Current controlled medication accountability records and audit records are kept by the nursing care center. When completed, audit and accountability records are kept on file according to state and federal regulations.(Photographic Evidence Obtained)

Based on observation, record review and interviews the facility failed to ensure medications were stored and labeled in accordance with professional standards. Observations included refrigerated medications stored outside of required temperature controls, medications lacking open dates, and failure to properly dispose of single-dose vials after use in one med cart (600) of six medication carts sampled.Findings Included: On 4/8/26 at 9:57 a.m. during interview, observation and narcotic count verification of the 600 Hall cart with Staff C, Licensed Practical Nurse (LPN). An opened undated vial of Ativan 20mg/10ml (milligram/milliliter) was in the controlled medication drawer. The clear plastic bag containing the vial was affixed with a sticker containing but not limited to, resident's name, medication issue date 9/24/25, medication strength and instructions to keep in the refrigerator. The label on the vial did not have an open or expiration date written on the label and the vial did not contain markings to check the volume of the medication. Staff C, LPN said she knows there is 9.75mls in the vial and showed the controlled drug declining inventory sheet showing on 12/19 at 9:00 a.m. 0.25 ml was administered and 9.75 milliliters remained in the vial. She said she does not know how long the medication had been stored in the drawer and did not respond when asked if the medication should be refrigerated. Staff C, LPN said the medication label should list the expiration date. (Photographic evidence obtained).On 4/8/26 at 3:39 p.m. during a telephone interview in reference to the Ativan 20mg/10ml stored in the medicate cart, the facility pharmacy services pharmacist said the prescription was filled on 9/24/25. She said, I would not expect the vial to be in use at this time. It was a one-time dose, not for multiple doses and has to be stored in the refrigerator.On 4/8/26 at 11:00 a.m. during an interview with the Director of Nursing (DON) regarding the vial of Ativan 20mg/10ml found in the 600 Hall medication cart, she said, Should have been wasted a long time ago.A review of facility policy titled Controlled Medication Storage, dated 1/26 revealed the following: Policy- Medications included in the Drug Enforcement Administration (DEA) or state classification as controlled substances are subject to special handling, storage, disposal and record keeping in the nursing care center in accordance with federal, state and other applicable laws and regulations.4. Controlled medications requiring refrigeration are stored within a separately locked, permanently affixed box within the refrigerator. The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule Il of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.14. Outdated, contaminated, discontinued or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are immediately removed from stock, disposed of according to procedures for medication disposal .15. Medications awaiting destruction that cannot be disposed of immediately should be recorded on a log to include the name of the individual(s) storing the medication, resident name, the prescription number if applicable, the quantity of the medication, the strength of the medication and the date of disposition. These medications should be stored in a secured area separate from active orders .

Based on review of facility records, staff and resident interviews, the facility failed to ensure sufficient staffing to meet the needs of the residents as evidenced by, 1. Resident interviews on untimely call light response for five residents (#11, #14, #15, #10 and #16) of 8 residents sampled, 2. Unresolved grievances related to call light response times for one resident (#11) of five residents reviewed for grievances. Findings included: On 3/10/25 at 2:20 p.m., an interview was conducted with Resident #11 who stated, depending on who's working the call light response varies. Resident #11 said, There is definitely a problem on nights and weekends where it can be up to an hour before someone answers the call light. A review of Resident #11's admission record revealed the resident was admitted to the facility on [DATE], with diagnoses to include nontraumatic intracerebral hemorrhage, muscle wasting, and atrophy. Review of Resident #11's Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 14, meaning intact mental cognition. A review of section GG of the MDS revealed Resident #11 is dependent for chair-to-bed transfers, substantial/maximal assistance for toileting and showering, moderate assistance for dressing, and set-up/clean-up assistance for eating. On 3/10/25 at 2:27 p.m.an interview was conducted with Resident #14. Resident #14 said he has always had an issue with call lights not being answered and he feels staff are irritated any time they come to assist him. Resident #14 said staff told him not to use the call light anymore and that it was just for the nurses. He stated he only uses the call light when he really needs it because he, doesn't want to cause problems. Review of Resident #14's MDS revealed a BIMS score of 15, meaning intact mental cognition. A review of the MDS Section GG: Functional Abilities revealed Resident #14 is dependent for toileting and showering, requires moderate to maximal assistance for dressing and personal hygiene, and requires set up assistance for eating and oral hygiene. On 03/10/2025 at 2:25 p.m., during an interview Resident #15 stated he had been a resident at this facility since 2011. He said about call lights, they've always been bad about answering call lights. Resident #15 stated now he just yells to get staff's attention. A review of Resident #15's admission record revealed the resident was admitted on [DATE] and readmitted on [DATE] with diagnoses to include unspecified sequelae of unspecified cerebrovascular disease as well as mixed hyperlipidemia, primary hypertension, type 2 diabetes mellitus without complications, and major depressive disorder. Review of Resident #15's MDS revealed a BIMS score of 14, meaning intact mental cognition. A review of Section GG: Functional Abilities revealed the resident is fully dependent for transferring and to requires substantial/maximal assistance for eating, oral hygiene, and dressing. On 3/10/25 at 10:45 a.m., an interview was conducted with Staff F, Certified Nursing Assistant (CNA). Staff F said, we have enough staff today to complete showers, but that is not always the case. She stated sometimes they did not complete the shower schedule and therefore some residents did not receive their showers or baths as scheduled because they did not have enough staff. On 3/11/25 at 10:30 a.m., an interview was conducted with Staff A, CNA, revealing staffing can be difficult. She stated it was more of an issue of staff calling out or staff showing up to work and then leaving. She stated scheduling can be short too. Staff A, CNA said that she feels like they can answer call lights and respond to resident needs in a timely manner when they have the right staffing. She stated if they're short staffed it can be difficult and busy. During an interview on 3/11/2025 at 10:45 a.m., Resident #16 said staff response to call lights was frequently brought up during resident council meetings. She stated it was mentioned in most meetings that staff took a long time to respond to call lights. Resident #16 expressed concerns about the administrative response to Resident Council, stating she felt like even though the meeting minutes are provided to the administrator, it never seemed to get addressed and there was no follow-up. Review of Resident #16's MDS, dated [DATE], revealed a BIMS score of 15, meaning intact mental cognition. Further review of the MDS Section GG: Functional Abilities revealed the resident required substantial/maximal assistance for transferring, dressing, and toileting and setup assistance for eating and oral hygiene. On 3/11/25 at 12:45 p.m. an interview was conducted with Staff I, Physical Therapist (PT). She said frequently she has found residents with urine-soaked disposable pads/underpants and/or linen. She stated residents have frequently told her staff have not responded to their call lights or they have not been changed from the previous evening. On 3/12/25 at 9:30 a.m. an interview was conducted with Staff E, LPN. She said fewer nurses are scheduled on the weekends. She stated frequently at the end of her shift she remains at the facility for up to two additional hours to complete her assignments. During a tour of 200 hall on 3/12/25 at 9:25 a.m., an observation was made of an unidentified resident yelling for staff's assistance. Staff E, LPN told the resident as soon as the CNA returned in about five minutes, assistance will be provided. At 9:55 a.m. the Director of Nursing (DON), who happened to be walking down the hall provided assistance to the resident. At 10:03 a.m. Staff B, CNA returned to the assigned hall. Staff B, CNA did not identify who was responsible for answering her call lights during her absence. During morning tour conducted on 03/12/2025 at 9:35 a.m.,, an observation was made of two call lights on. Nursing staff were not observed answering the calls. It was not clear how long they had been on. The nursing Home Administrator (NHA) happened to be walking by and answered both call lights. It was not clear where the CNA's assigned to the hall were. Review of Resident Council meeting minutes for January, February and March 2025, showed there were no concerns documented related to call light response and/or incontinent care concerns, contrary to Resident #16's statement. An interview was conducted with the NHA on 3/12/25 at 12:51 p.m. about a grievance for Resident #11. The grievance dated 1/22/25 showed under concern, prolonged call lights response time. The NHA stated Resident #11 revealed she had been waiting more than 15 minutes. The NHA stated if the response was within 15 minutes it is okay. The NHA could not identify how long the resident had waited to be assisted. During an interview with Resident #11 on 3/10/25 at 2:20 p.m., the resident stated, it can be up to an hour before someone answers the call light. On 3/11/25 at 2:40 p.m. an interview was conducted with the Nursing Home Administrator, (NHA). The NHA stated call light audits were started in September 2024, and Quality Assurance and Performance Improvement (QAPI) initiative focused on call light responses. The NHA said this issue was identified as a result of complaints from residents and resident families. The NHA could not confirm if the call light audits or QAPI initiative had been successful. A policy related to Activities of Daily Living (ADL) was requested and not provided. 51097 During an interview with Resident #10 on 03/10/25 at 12:45 p.m. he stated, The staff do not answer my call light. He further stated he could not get his call light answered when he needed help. During an interview on 03/12/25 10:30 a.m. with Staff H. Registered Nurse (RN), Unit Manager (UM), he confirmed they were short-staffed a CNA today. He stated they are short-staffed sometimes. 50570 On 3/12/25 at 9:30 a.m., an interview with Staff C, Licensed Practical Nurse (LPN) revealed sometimes her tasks rolled over to the next shift due to not having enough staff. She stated she completes tasks from the previous shift as the, 11 p.m. to 7 a.m. shift is not fully staffed. Staff C, LPN stated the, 7 a.m. - 3 p.m. shift is not always fully staffed as well. She stated she did not have enough time to complete some of her nursing tasks sometimes. Staff C, LPN stated she typically had 30-31 residents on her assignment. She stated when fully staffed, she would have about 20 residents on her assignment. She stated when there is a lot of call outs, and no replacement staff then, It's difficult to do my job. Staff L, LPN stated she would assist CNAs with showering/bathing residents if needed when they are short staffed, but it's not her usual role. On 3/12/25 at 11:20 a.m., an interview with the Activities Director (AD) revealed she is the liaison and documented the minutes during resident council meetings. The AD stated if concerns are brought up during resident council, she documented on the grievance form, Resident council, and provided that to the interdisciplinary department it belonged to. The AD stated she had not had to fill out a grievance form for recent resident council meetings. She stated, A few months back, a resident presented a concern about call lights, therefore, audits were initiated. The AD stated she filled out a grievance for that resident and gave it to the social services director (SSD). The AD stated she thought the facility's expectations regarding answering call lights was to answer within 10 minutes, but that was not always the case. She stated the expectation was to, try to answer the call light in a timely manner. If you see the call light, anyone can answer. Everybody here is supposed to answer call lights. She stated if the resident needed something out of the scope of the person who answered the call light, then they should get the appropriate person. On 3/12/25 at 1:20 p.m., an interview was conducted with the Staffing Coordinator (SC) who revealed the facility is staffed based on acuity and census. She stated she received census numbers from the morning meeting. The SC stated she gathered information about acuity based on the calculated census per the number of staff. She stated she would receive information from the Assistant Director of Nursing (ADON) in the morning or the night before, regarding acuity and resident needs. The SC stated if there was a call out, she would call other staff to see if they can come in. She stated if no one could come in, they adjust the assignments to make it as even as possible. The SC could not confirm if some tasks were not completed as a result of a lack of replacement. On 3/11/25 at 2:15 p.m. an interview with the Nursing Home Administrator (NHA) revealed she attended resident council meetings when invited, or when there is something that affected the facility that residents needed to know. She stated the Activities Director (AD) takes meeting minutes during resident council meetings. The NHA stated if there was an individual concern, then a grievance form is completed. The NHA stated she conducted daily meetings with department heads, where they discuss resident council concerns. The NHA stated regarding call light concerns, there was a concierge program that is conducting on-going call light audits. She stated concierge rounds were conducted daily, and findings are discussed in the daily meetings with department heads. She stated if a resident had any concerns, she would initiate a grievance immediately based on concerns presented in concierge rounds. The NHA did not confirm if the call light audits had addressed the resident's concerns related to delayed response times. Review of a Job description titled, Position - Director of Nursing (DON), dated August 2022, showed, under essential duties, Makes rounds to note resident/patient conditions and to ensure nursing personnal are performing their work assignments in accordance with acceptable nursing standards. Assures adequate staffing of the facility on a 24 - hour basis A policy related to timely call light response was requested and not provided. A policy related to staffing was requested and not provided.

Based on interview and record review, the facility failed to ensure Hemodialysis (HD) care was provided per physician orders for one (Residents #1) of six residents receiving dialysis. Findings included: Resident #1 was admitted to the facility on [DATE] and discharged on [DATE] with diagnoses to include End Stage Renal Disease (ESRD) and Dependence on renal dialysis. Review of the facility's grievance log showed on 03/11/24, a grievance was filed for Resident #1. Review of the grievance submitted by the resident's family member showed Resident missed dialysis on 03/09/24 and was late on 03/07/24 due to transportation. Review of physician orders for Resident #1 dated 03/06/24 showed the resident did not have orders for hemodialysis. Review of physician orders for Resident #1 dated 04/02/24 showed the resident is to have Dialysis on days: Tuesday, Thursday, Saturday at [name and location of Dialysis center] Chair time: 6 AM Catheter site: Right and Left Upper Arms Dialysis Transport:[name of transportation company], Name/Phone Number of the doctor and bag meal/snack to go with resident name. Document Vital signs upon resident returning from dialysis. Dialysis AV (Arteriovenous) Shunt - Monitor every shift for signs and symptoms of bleeding. Location of shunt Right and Left upper Arm. every shift for Preventative Measure Notify MD if bleeding occurs. Dialysis Catheter Site Right and Left upper arms. Monitor every shift for signs and symptoms of bleeding. every shift for Prevention Notify MD of bleeding. Epogen to be given at Dialysis center during Dialysis. Review of care plan for Resident #1 dated 03/07/24 showed, CANCELED: HEMODIALYSIS: The resident has renal failure and is on Hemodialysis. Resident to have Dialysis on days: Tues, Thurs, Sat. Interventions included Resident to have Dialysis on days: Tues, Thurs, Sat at [name of dialysis center and the transportation company]. Dialysis Catheter Site- Observe for Signs and Symptoms of Bleeding. Observe for Bleeding; for gross bleeding at access consider calling 911. Diet as ordered. Protect shunt site from injury: No constriction or BP to affected limb. Observe for change in appearance/unusual bleeding at site. Observe signs and symptoms of infection and injury at access site. Redness, pain, drainage, loss of feeling in extremity, edema, ischemic skin changes. Encourage resident to go for the scheduled dialysis appointments. Encourage rest as needed and participation in preferred activities. Allergies No Known Allergies. Review of the Medical Certification for Medicaid Long-Term Care Services and Patient Transfer Form (Form 5000-3008) dated 03/06/24, showed Resident #1 received dialysis on Tuesday, Thursday, and Saturday. Review of a facility document titled, Pre-admission Screening Tool, dated 03/05/24, showed Resident #1 required HD on Tuesday, Thursday, and Saturday. The document indicated [name of dialysis facility] and the chair time, 6 a.m. Review of a document titled, SBAR (Situation Background Assessment Recommendation) Communication Form dated 03/09/24 at 10:15 a.m. showed, MD (Medical Doctor) at dialysis center requested [Resident #1] be sent to [name of the hospital] for dialysis treatment. Review of a facility Hospital Transfer form, dated 03/09/24 at 10:00 a.m., showed Resident sent to hospital for dialysis treatment. On 04/02/26 at 10.06 a.m., an interview was conducted with Staff A, Licensed Practical Nurse, (LPN). She stated she had dialysis residents in hall 600. She stated to her knowledge her residents had not missed dialysis. She said, But, there was a resident on the other side, earlier in March, she missed two dialysis appointments because of transportation. She ended up being hospitalized . I heard the transport bus broke or something. She was not assigned to me directly. Staff A stated she made sure the Certified Nurses Assistants (CNAs) got the residents up on time. She stated they did not want them to miss their chair time. She stated the nurses completed documentation before and after dialysis. On 04/02/26 at 10:12 a.m., an interview was conducted with Staff B, Registered Nurse (RN)/ Unit Manager. She stated she had a dialysis resident in hall 300. She stated there were times residents missed appointments because of the transport company. She stated they could be unreliable. She stated Medical Records scheduled all dialysis transportation. She stated the facility did not have an emergency plan and they do not have a vehicle. She said, The plan is to reschedule the appointment for the next day or get orders to send the resident to the hospital. She stated each resident had a dialysis communication book they brought to the center for dialysis staff to fill out. She stated their nurses fill out their portion for post dialysis care. On 04/02/26 at 10:20 a.m., an interview was conducted with Staff C, LPN. She stated the only issue they had was with transportation, which would normally be set up by Medical Records. She stated the nurses filled out the form, gave the resident their medications, and gave them a meal from the kitchen. She stated they would try and get them in for a later chair time. She stated she made repeated calls to the transportation company and if they could not get them in, they notified dialysis and the doctor. She stated she was not aware of any residents missing dialysis recently. An interview was conducted with the Director of Nursing (DON) on 04/02/26 at 11:18 a.m. She stated Resident #1 was admitted to the facility on [DATE] and had dialysis set up. She said, It was set up for Tuesday, Thursday and Saturday, chair time at 6 a.m. She stated the hospital typically sets up the first appointment, but in this case they did not. When she was admitted she was not able to get in for the 6 a.m. chair time which was scheduled for the following day. We called and rescheduled. She went in at 8:30 a.m. and had a shortened chair time. She returned at 12:30 p.m. The DON stated a shortened chair time meant dialysis shortened her chair time and she did not know why. She said it had to do with their scheduling. The DON stated transportation did not show up for her 6 a.m. chair time again on 03/07/24. She stated when the nurse called, they kept saying they were on their way. The DON stated the nurse on duty called the doctor, and eventually around 10 a.m. he ordered her to be transferred to the hospital. The DON stated their protocol if a resident missed an appointment was to call the dialysis center and set up a later chair time. The DON stated the facility had no vehicle available. They could not transport her. The DON stated they had analyzed the situation and the previous NHA was supposed to file a complaint with the insurance company. I don't know if it was filed. We notified the daughter of the appointments. The DON stated no other residents had missed dialysis. On 04/02/26 at 12:09 p.m., the DON stated they had reviewed the incident which happened on a weekend. She stated Medical Records did not work weekends. She stated the weekend supervisor should have confirmed the chair time and transportation. The DON said, to my knowledge, I don't know if anyone called to confirm the appointments prior to her admission or upon admission. The DON stated there was no evidence it was confirmed because it was not documented. On 04/02/26 at 12:38 p.m. an interview was conducted with the Nursing Home Administrator (NHA) and the DON. The NHA stated she had just become aware of Resident #1 missing dialysis appointments. She said, I can't speak of that incident, but for the future we will make sure transportation for dialysis residents is secured. It normally takes them time to make sure the residents are ready. The DON stated the facility had gone through a staffing turnover. She stated they had identified they needed to put some systems in place. She stated they had started in-services on documentation. She stated they would educate on dialysis. On 04/02/26 at 12:12 p.m., the DON stated they had received a grievance for this patient. She stated to her knowledge they had resolved it for this patient. She said, We have no control of the transportation company. The DON stated they had a contingency plan. She said, We have other transportation companies that we could call. And the facility could pay for the transport. This is our emergency plan. I don't have the answer as to why this did not happen. The weekend supervisor dealt with that. I don't know if the nurses know of this option. The weekend supervisor chose to call the doctor and send her out. I know the hospital is for acute care. It is not for regular non-emergent services. I know. We will educate the nurses. Review of dialysis communication books for March 2024 revealed the following: There was one documented communication form dated 03/07/24. The pre- dialysis care portion was noted blank. The DON stated the dialysis forms should be filled out completely. She stated it was tool for the center and the facility to communicate. She stated the vitals should be documented and the site should be assessed. She stated they were to notify the doctor of anything out of the ordinary. Review of a facility policy titled, Dialysis Management (Hemodialysis), dated October 2021, showed the facility will coordinate care and services for hemodialysis residents. Facility will coordinate routine transportation for the resident. Contractual agreement will include but not limited to, the following: Medical and non-medical emergencies, development and implementation of resident care plan, interchange of information useful/necessary for the care of the resident. Under guidelines 1.) obtain physician orders to include but not limited to shunt access site-signs and symptoms to monitor such as pain, infection, or bleeding. 4.) Daily assessment and documentation of shunt or access site for bleeding, signs and symptoms of infection, redness/pain. Notify physician of abnormal findings. 8.) Complete the dialysis communication tool before and after dialysis and following up on any special instructions from the dialysis center.

Based on interviews and record review the facility failed to ensure one resident (#81) out of five residents sampled was accurately assessed for pain in Section J- Health Conditions on the Minimum Data Set (MDS) assessment. Findings included: During an interview on 01/09/24 at 9:45 a.m., Resident #81 stated she had pain in her feet. Resident #81 could not answer why her feet hurt but stated, They just hurt. Review of Resident #81's Admission Record showed diagnoses including muscle wasting and atrophy, multiple sites, chronic pain syndrome, low back pain, foot drop, and pain unspecified. Review of Resident #81's current physician orders showed the following medications for pain: - A physician order dated 10/09/23 showed Baclofen Oral Tablet 10 MG [milligrams] give one tablet by mouth three times a day for pain. - A physician order dated 10/10/23 showed Norco Oral Tablet 5-356 MG [milligrams] give one tablet by mouth every six hours as needed for pain. - A physician order dated 11/10/23 showed Lidocaine HCI External Patch 4% apply to lower back topically one time a day for pain. Review of Resident #81's Quarterly Minimum Data Set (MDS), dated [DATE], Section J- Health Conditions showed questions A. Been on a scheduled pain medication regimen? and B. Reviewed PRN pain medications? were marked No. Review of Resident #81's December 2023 Medication Administration Record (MAR) showed Resident #81 received Baclofen oral tablet 10 MG was administered three times a day for pain 12/01/23-12/09/23, Lidocaine HCI External Patch 4% was applied once a day for back pain on 12/01/23-12/09/23, and Norco Oral Tablet 5-356 MG [milligrams] was given on 12/09/23 during the time period of 12/01/23-12/09/23. Review of Resident #81's care plan showed, Pain: The resident has pain and a potential for pain. Pain to the lower back, joints and generalized. Back pain and generalized at times. Goals: The resident will not experienced a decline in overall function related to pain through the review date. Interventions: Administer medications and observed for effectiveness, Observe and report signs of s/sx of pain, pain management consult and consult order for psychological services. Review of Resident #81's Quarterly MDS, dated [DATE], showed a modification was made on 01/11/24 at 2:44 p.m. The modification showed Section J- Health Conditions showed question B. Reviewed PRN pain medications? now reflected the answer changed to Yes. (Photographic evidence obtained) During an interview on 01/12/24 at 9:30 a.m., Staff B, MDS Coordinator stated he did modify Resident #81's Quarterly MDS, dated [DATE], yesterday. Staff B, MDS Coordinator stated no one asked him to modify the MDS, however when he was asked to print Resident #81's MDS he noticed Section J- Health Conditions was marked wrong with the pain medications marked no. Staff B, MDS Coordinator stated Administration asked me to print the MDS sections so I checked them to make sure they were right before I printed them because I knew you were in the building and auditing them. Staff B, MDS Coordinator stated I wanted to make sure the MDS was correct before printing and giving it to you for review. During an interview on 01/12/24 at 9:40 a.m., the Administrator stated, I would not expect my staff to change documents after you have asked for them. The Administrator stated, I would expect them to print the original incorrect form to give to you and then fix the discrepancy.

Based on record review and interviews the facility failed to refer one resident (#78) of 12 residents reviewed for Pre-Admission Screening and Resident Review (PASRR), for a Level II review after a positive Level I PASRR revealed a need for further review. Findings included: Review of Resident #78's Admission Record showed an original admitted [DATE] with diagnoses included but not limited to unspecified mood [Affective] disorder onset date 07/28/23, other psychotic disorder onset date 07/28/23, Schizoaffective Disorder, Bipolar Type onset 12/14/23, Major Depressive Disorder, recurrent, moderate onset date 12/14/23, Schizoaffective Disorder, unspecified onset date 07/28/23, Bipolar Disorder, unspecified onset date 07/28/23 and generalized anxiety disorder onset date 10/19/23. Review of Resident #78's Discharge Return Anticipated Minimal Data Set (MDS) assessment dated [DATE], revealed under Section C-Cognitive Patterns, Resident #6 had a Brief Interview for Mental Status (BIMS) of 03 (severe cognitive impairment) and under Section I - Active Diagnoses, Resident #6 had diagnoses of Anxiety Disorder, Manic Depressive-Bipolar Disease, Psychotic Disorder and Schizophrenia. A review of Resident #78's I PASRR assessment, dated 07/14/23 revealed, under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder were checked. The assessment also revealed, under the section III titled Other Indications for PASRR Screen Decision-Making, the checkboxes for the selection B Concentration, persistence and pace was checked Yes. The assessment further revealed, under section IV titled, PASRR Screen Completion, the selection Individuals may not be submitted to a Nursing Facility. Use this form as required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of Serious Mental Illness and Intellectual Disability. Further review of Resident #78's medical record showed no Level II PASRR available for review. During an interview on 01/12/24 at 10:38 a.m., the Director of Nursing (DON) stated she was responsible for all Residents' PASRR with the help from the Social Worker. The DON stated she would expect all the PASRR information to be included in the hard copy chart for all Residents. The DON reviewed Resident #78's PASRR dated 07/14/23 which showed under the section titled A. MI (Mental Illness) or suspected MI (check all that apply), the checkboxes for the selections Depressive Disorder, Bipolar Disorder, and Schizoaffective Disorder were checked. The assessment also revealed, under the section III titled Other Indications for PASRR Screen Decision-Making, the checkboxes for the selection B Concentration, persistence and pace was checked Yes. The assessment further revealed, under section IV titled, PASRR Screen Completion, the selection Individuals may not be submitted to a Nursing Facility. Use this form as required documentation to request a Level II PASRR evaluation because there is a diagnosis of or suspicion of Serious Mental Illness and Intellectual Disability. The DON stated let me look into this as no Level II PASRR was available in Resident #78's medical record. During an interview on 01/12/24 at 11:00 a.m., the DON provided a [company name] statement Preadmission Screening and Resident Review Screening dated 10/26/23 that showed, We cannot complete the screening. The reason is below: The case is being closed due to an incomplete submission packet. Written in the top right corner showed faxed all 11/13. The DON stated that she would have to continue to look further to see if the information was re-submitted for the level II. During an interview on 11/12/24 at 11:23 a.m., the DON stated she had a call out to [the state reviewing agency] because she looked in the electronic system and did not see where a new submission within [The state reviewing agency] online system was submitted for Resident #78 on 11/13/23. The DON stated she could not find any fax confirmation for any re-submission of a completed submission packet. The DON stated right now she did not have any proof or evidence that the facility ever completed a Level II review for Resident #78.

Based on interviews and record review, the facility failed to implement and develop a care plan for a Functional Maintenance program/Restorative Nursing program for one resident (#17) out 34 sampled residents. Findings included: Review of Resident #17's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she feels she is not able to lift herself from the wheelchair and use her walker as well as she used to. She said she feels weaker now. She said she told the Nursing Home Administrator (NHA), but she has not heard anything from him since. Review of Resident #17's physician orders revealed an order with a start date of 7/25/23 with no end date for Restorative Nursing as needed. Review of Resident #17's TO (Occupational Therapy)-Therapist Progress & Discharge Summary dated 12/6/23 revealed the following. Analysis of Functional Outcome/Clinical Impression Pt [patient] provided with skilled OT to increase independence in ADL performance and related mobility. Pt made measurable progress attaining all of her long-term goals. Pt provided with Functional Maintenance program for BUE [bilateral upper extremities] ROM [range of motion]/strengthening exercises to maintain with provision of skilled OT. Review of Resident #17's Therapy Recommendations for Restorative/Functional Maintenance Program with a therapy discharge date of [DATE], revealed Passive and/or Active Assistance/ROM [range of motion] BUE [bilateral upper extremity] strengthening/ ROM exercises: Strengthening: using light resistance theraband [sic] 1lb [pound] hand weight, 2lb weighted [sic] 10 reps X [times] 3: Shoulder flex/ext [extension]/abduction. -Biceps curls -Triceps extensions. .General Recommendations: Pt to perform upper body exercises to maintain/increase strength to performance of basic self care tasks and transfers. The training record revealed 3 signatures. One Licensed Practical Nurse (LPN) signature dated 12/7/23. One Certified Nursing Assistant (CNA) signature dated 12/7/23, and Staff A, CNA signature dated 1/4/24. Review of Resident #17's care plans did not reveal a care plan related to her Functional Maintenance program/Restorative program with measurable goals and interventions. An interview was conducted on 1/11/24 at 11:57 AM with the NHA. He said since the resident has been admitted he had been working very closely with the family and the resident regarding therapy. We actually just had a care plan meeting this morning for her and we are going to get her rescreened for therapy .we just reviewed all the therapy notes and she is stand by assist for all her ADLs and walking over 150 feet .this morning she said she's not confident getting up and walking so we just put in a therapy referral but we extended her therapy several times while she has been here to get her ready to go to an ALF [Assisted Living Facility]. An interview was conducted with the Director of Therapy (DOR) on 1/11/24 at 1:20 p.m. She said, Resident #17 was on Physical Therapy (PT) from 7/26/23 through 12/26/23. The resident received Occupational Therapy (OT) from 7/26/23-12/06/23 and she is currently on Speech Therapy for cognition. The DOR said When she was discharged from therapy, she was walking over 150 feet with supervision to stand by assist with the rolling walker. Stand by assist means we have a wheelchair there just in case if she needs to take a break or is feeling anxious. She was a standby assistant with transfers. That means someone is close enough to reach her if assistance is needed. When we discharged her from PT and OT, we discharged her with the restorative program, but our restorative aide no longer works here and there hasn't been a restorative aide for a while. When we discharge a resident to the restorative program, we write up a restorative plan and educate the CNAs on it but I can't be sure it is actually getting done. An interview was conducted with Resident #17 on 1/11/24 at 2:30 p.m. She was observed to be in her room sitting in her wheelchair with a [brand name therapy band] on her bed next to her. She said since I have stopped therapy, I have been getting zero exercise. I have this band and I will stretch it sometimes, but I am doing that myself and it isn't helping, I am getting weaker. I am going backwards because I'm not getting the exercises. I don't know what a Restorative Program is. I don't have weights, and no one brings me weights to do exercises. An interview was conducted with Staff A, CNA on 1/11/24 at 2:40 p.m. she said she works with Resident #17 every Tuesday and Thursday. She said she doesn't know anything about a Restorative program. We used to have a restorative aide, but he has not been here for a long time. If the residents need exercises that's something Therapy does. Staff A, CNA said she does not provide Resident #17 with exercises using weights or bands, That's something therapy does. An interview was conducted with the Director of Nursing (DON) on 1/11/24 at 4:03 p.m. She said we do not have a restorative program. I was never oriented to a restorative program since I started on October 31st, 2023. An interview was conducted with the DOR on 1/11/23 at 9:28 a.m. She said, The facility is supposed to provide the residents with restorative therapy according to our contract with them and I'm not sure it is actually getting done. Review of the facility's policy Care Plan- Interdisciplinary Plan of Care from Interim to Meeting with a revision date of September 2023 revealed the following. Policy The facility shall support that each resident must receive [sic] and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. The facility shall assess and address care issues that are relevant to individual residents, to include, but may not be limited to monitoring resident condition and responding with appropriate interventions. The comprehensive care plan is an interdisciplinary communication tool. It includes measurable objectives and time frames and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan is reviewed and revised periodically, and the services provided or arranged are consistent with each resident's written plan of care

Based on interviews and record review the facility failed to provide a Functional Maintenance program/Restorative Nursing program to maintain or improve resident activities of daily living (ADLs) for one resident (#17) out three residents reviewed for activities of daily living. Findings included: Review of Resident #17's Admission Record revealed she was admitted to the facility on [DATE] from an acute care hospital. Her diagnoses included but are not limited to lack of coordination, repeated falls, unsteadiness on feet, need for assistance with personal care, cognitive communication deficit, acquired deformities of right foot, age related physical debility, personal history (healed) of traumatic fracture, and presence right artificial hip joint. An interview was conducted on 1/9/24 at 10:22 AM with Resident #17. She was observed to be in her room sitting in her wheelchair. She said she was not currently in therapy, but she feels she was making progress in therapy and now that she is no longer in therapy she feels she is not able to lift herself from the wheelchair and use her walker as well as she used to. She said she feels weaker now. She said she told the Nursing Home Administrator (NHA), but she has not heard anything from him since. Review of Resident #17's physician orders revealed an order with a start date of 7/25/23 with no end date for Restorative Nursing as needed. An interview was conducted on 1/11/24 at 11:57 AM with the NHA. He said since the resident has been admitted he had been working very closely with the family and the resident regarding therapy. We actually just had a care plan meeting this morning for her and we are going to get her rescreened for therapy .we just reviewed all the therapy notes and she is stand by assist for all her ADLs and walking over 150 feet .this morning she said she's not confident getting up and walking so we just put in a therapy referral but we extended her therapy several times while she has been here to get her ready to go to an ALF [Assisted Living Facility]. An interview was conducted with the Director of Therapy (DOR) on 1/11/24 at 1:20 p.m. She said, Resident #17 was on Physical Therapy (PT) from 7/26/23 through 12/26/23. The resident received Occupational Therapy (OT) from 7/26/23-12/06/23 and she is currently on Speech Therapy for cognition. The DOR said When she was discharged from therapy, she was walking over 150 feet with supervision to stand by assist with the rolling walker. Stand by assist means we have a wheelchair there just in case if she needs to take a break or is feeling anxious. She was a standby assistant with transfers. That means someone is close enough to reach her if assistance is needed. When we discharged her from PT and OT, we discharged her with the restorative program, but our restorative aide no longer works here and there hasn't been a restorative aide for a while. When we discharge a resident to the restorative program, we write up a restorative plan and educate the CNAs on it but I can't be sure it is actually getting done. Review of Resident #17's OT-Therapist Progress & Discharge Summary dated 12/6/23 revealed the following. Analysis of Functional Outcome/Clinical Impression Pt [patient] provided with skilled OT to increase independence in ADL performance and related mobility. Pt made measurable progress attaining all of her long-term goals. Pt provided with Functional Maintenance program for BUE [bilateral upper extremities] ROM [range of motion]/strengthening exercises to maintain with provision of skilled OT. Review of Resident #17's Therapy Recommendations for Restorative/Functional Maintenance Program with a therapy discharge date of [DATE], revealed Passive and/or Active Assistance/ROM [range of motion] BUE [bilateral upper extremity] strengthening/ ROM exercises: Strengthening: using light resistance [therapy band name] [sic] 1lb [pound] hand weight, 2lb weighted [sic] 10 reps X [times] 3: Shoulder flex/ext [extension]/abduction. -Bicep curls -Tricep extensions. .General Recommendations: Pt to perform upper body exercises to maintain/increase strength to performance of basic self care tasks and transfers. The training record revealed 3 signatures. One Licensed Practical Nurse (LPN) signature dated 12/7/23. One Certified Nursing Assistant (CNA) signature dated 12/7/23, and Staff A, CNA signature dated 1/4/24. An interview was conducted with Resident #17 on 1/11/24 at 2:30 p.m. She was observed to be in her room sitting in her wheelchair with a therapy band on her bed next to her. She said since I have stopped therapy, I have been getting zero exercise. I have this band and I will stretch it sometimes, but I am doing that myself and it isn't helping, I am getting weaker. I am going backwards because I'm not getting the exercises. I don't know what a Restorative Program is. I don't have weights, and no one brings me weights to do exercises. An interview was conducted with Staff A, CNA on 1/11/24 at 2:40 p.m. she said she works with Resident #17 every Tuesday and Thursday. She said she doesn't know anything about a Restorative program. We used to have a restorative aide, but he has not been here for a long time. If the residents need exercises that's something Therapy does. Staff A, CNA said she does not provide Resident #17 with exercises using weights or therapy bands. That's something therapy does. An interview was conducted with the Director of Nursing (DON) on 1/11/24 at 4:03 p.m. She said we do not have a restorative program. I was never oriented to a restorative program since I started on October 31st, 2023. An interview was conducted with the DOR on 1/11/23 at 9:28 a.m. She said, The facility is supposed to provide the residents with restorative therapy according to our contract with them and I'm not sure it is actually getting done. Review of the facility's policy Restorative Nursing Programs and Guidelines with a revision date of October 2017 revealed the following: Overview The facility provides Restorative Nursing Programs that involve interventions to improve or maintain the optimal physical, mental and psychological functioning. The IDT [interdisciplinary team], resident and, or family identify the needs of the resident, and collaboratively determines appropriate Restorative Nursing Programs to achieve the resident's goals. The programs include: Contracture Management and Prevention -This program includes the provision of active and, or passive range of motion exercises/movements to maintain or improve joint flexibility as well as strength. This program also involves splint/brace assistance to protect joint and skin integrity. Mobility- This program improves or maintain self-performance in bed mobility, transfers, wheelchair mobility and walking. Activities of Daily Living- This program involves improvement or maintenance of the resident's self performance in dressing (including prosthetic care), grooming and bathing .

Based on observations, record review, and interviews, the facility failed to maintain emergency supplies for tracheostomy care at bedside per physician's order and failed to obtain orders prior to administering oxygen for one resident (Resident #14) out of two sampled residents. Findings included: On 01/10/24 at 9:30 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters. On 01/12/24 at 9:40 a.m., the oxygen concentrator in Resident #14's room was observed on and set at 5 liters, the humidified air was set at 28%. The opposite end of the tubing connector attached to the oxygen concentrator was observed disconnected from the tracheostomy (trach) collar and on the floor. A review of the Admission Record for Resident #14 showed the resident was initially admitted to the facility on [DATE] with diagnoses to include chronic respiratory failure with hypoxia, tracheostomy status, and respiratory disorders in diseases classified elsewhere. A review of the Quarterly Minimum Data Set (MDS), dated [DATE], Section O Special Treatments, Procedures, and Programs showed Resident #14 received the following respiratory treatments: oxygen therapy, suctioning, and tracheostomy care. A review of the Order Summary Report with active orders as of 01/12/24 revealed the following orders: Maintain Ambu bag at beside and replacement trach of equal size and one size down maintained at bedside every shift for preventative measure and Tracheostomy Type: Shiley size 6. Trach care daily and as needed. There was no order for oxygen found. A progress note dated 01/01/24 at 11:49 revealed intravenous antibiotic remains in progress for respiratory infection. Trach patient coughing up white secretions via trach. The care plan related to the tracheostomy initiated 04/26/17 revealed Resident #14 had a tracheostomy related to impaired breathing mechanics. Interventions included to give humidified oxygen per trach as tolerated, oxygen as ordered via trach, and maintain Ambu bag and replacement trach at bedside per order. On 01/12/24 at 9:42 am, Staff C, Licensed Practical Nurse (LPN), confirmed the oxygen concentrator was set at 5 liters. The tubing connector on the floor was pointed out and Staff C, LPN, stated she would change the tubing. Staff C, LPN was asked to verify the order for oxygen. She went to her computer, looked through the orders for Resident #14, and stated she could not find the order for oxygen. Staff C, LPN, then stated she would have to go verify the order for oxygen. The emergency supplies were observed. Observations revealed there was only a 6.4 and 6.5 Shiley located in the room. This was confirmed by Staff C, LPN, and Staff H, Registered Nurse (RN). Staff H, RN, stated he thinks the resident had a size 7 Shiley. The current physician's order revealed a replacement trach of equal size, and one size down should be maintained at bedside every shift and he had an order for a size 6 Shiley. Staff C, LPN, stated in the mornings she made sure everything was in place. She made her rounds to make sure the oxygen was on but didn't check the emergency supplies. On 01/12/24 at 10:28 a.m., the Director of Nursing (DON) stated no size 5 Shiley exists so a size 4 would be the next step down. She stated there should have been an order in place for oxygen. The DON walked down to Resident #14's room and she confirmed the correct size for the replacement trach was not in the room. There was only a 6.4 and 6.5 Shiley located in the room. The policy provided by the facility Emergency Tracheostomy Tube Changes with an effective date of December 2022 revealed the following: The following supplies are to be kept at the bedside in a highly visible area of any resident who has a tracheostomy tube: Tracheostomy tubes- one the same size and one a size smaller.

Based on observation, interview, and record review, the facility failed to ensure one (Resident #6) of 77 residents was assessed and deemed safe to self administer medications. Findings included: An observation on 03/14/23 at 10:00 AM, showed a souffle cup with a pill in it and a prescription cream on Resident #6's bedside table. Photogenic evidence was obtained. In an immediate interview on 03/12/23 at 10:00 AM, Resident #6 revealed the nurse would give him his pills and leave them at the bedside for him to take at his leisure. Resident #6 stated the physician ordered the cream for his bottom and the CNAs helped him administer it. During an interview on 03/14/23 at 10:05 AM, Staff A Licensed Practical Nurse (LPN) confirmed she administered Resident #6's pills today and stated, he must not have gotten all the pills down when he took them this morning leaving that pill in the cup. Staff A LPN was observed taking the souffle cup with the remaining pill in it away from bedside to discard. A record review of Resident #6's medical record showed an admitted [DATE] with a primary diagnosis of Cerebral Infarction, lack of coordination, muscle weakness, hemiplegia affecting left non dominant side and major depressive disorder, recurrent. Physician orders included: Gabapentin Capsule 300 for Neuropathy, Hydrocodone every 6 hours as needed for pain, Lisinopril Tablet 40 MG for HTN, Tamsulosin HCI Capsule 0.4 MG for supplement, Amlodipine Besylate Tablet for HTN. There was no physician order for self-administration of medications. Resident #6's annual Minimum Data Set (MDS) dated [DATE] showed a BIMS (Brief Interview for Mental Status) score of 11, which indicated moderately impaired cognition. The comprehensive care plan revealed a focus of Cognition: The resident has impaired cognitive function/dementia or impaired thought process related to moderately impaired BIMS score of 8-12. The intervention was to explain care before providing it. During an interview on 03/15/23 at 8:45 AM, the Director of Nursing (DON) stated the expectation was for nurses to administer medications and the facility had already put a plan in place to correct the problem. A review of the facility's policy titled, Medication Administration Section: 7.1 dated 09/2018, stated, 20. The Resident is always observed after administration to ensure that the dose was completely ingested. If only partial dose is ingested, this is noted on the MAR action is taken as appropriate.

Based on observation, interview, and record review, the facility neglected to 1. provide care and services in accordance with best practice for one (Resident #1) of one resident with a biliary drain. 2. neglected to provide enteral feeding and supplementation in a timely manner for one (Resident #1) of three residents sampled and 3. neglected to monitor and provide care and services for three (Residents #1, #4, and #5 ) out of three residents sampled with an enteral stoma site. Findings Included: 1. A review of the Nursing Home (NH) Follow up (F/U) dated 01/20/2023 for Resident #1 revealed the resident was seen for a visit status post (s/p) hospital admission. The patient was admitted for abdominal pain, abdominal wall cellulitis, and jejunostomy (J) tube site infection. A review of Admission Record form revealed Resident #1 was in her early sixties and resided at the facility for a total of seven days. Diagnoses: Gastrostomy status, infection following procedure, other surgical site, superficial incision surgical site, initial encounter, gastrostomy infection. A review of nursing notes dated 01/18/2023 at 7:32 a.m., revealed the resident was sent to [name of hospital]to replace bile stent. At 11:31 p.m. (23:31), Resident returned from hospital at 6:30 p.m. A review of the emergency room Patient Care Report dated on 01/18/2023 revealed, Narrative: Pt. is a (age and gender) transferred from [local hospital name] to [name of skilled nursing facility]. Pt states that she was getting her wounds cleaned and the staff cut her nephrostomy tube. Pt. stated that the staff said that her tube was caught on something, so she just cut it. RN states that they just replaced the nephrostomy tube and is discharging back to the facility. Pt. is A&O (alert and oriented) x (times)4, GCS-15 with decisional capacity intact. Glasgow Coma Scale (GCS) is a clinical scale used to reliable measure a person's level of consciousness. The number 15 indicating normal. A review of the Emergency Department Discharge Instructions dated on 01/18/2022 revealed, The existing biliary drain was noted to be cut/damaged. The end of the catheter injected contrast and demonstrated appropriate positioning within the gallbladder lumen. Therefore, a 0.038 guided wire was directed under fluoroscopic guidance through the existing tube into the gallbladder. The existing drain was removed entirety. Radiology Pre-Op Diagnosis: chole drain cut. A review of the Emergency Department Documents revealed, Chief Complaint: .Pt. had GB (gallbladder) procedure 3 days ago and has GB drain. NH staff cut the drain during dressing change. Reevaluation: Patient is also requesting to speak to social worker and says she does not want to go back to the facility from which she was transferred and prefers to be discharged home. On 03/14/2023 at 12:46 p.m., an interview was conducted with the Director of Nursing (DON). She confirmed she was aware of Resident #1 going out to the hospital. She indicated it was after a dressing change was performed and the biliary tubing was dislodged. She stated, the tubing to the bile stent needed to be replaced. When asked about the emergency room Patient Care Report that indicated the tube was cut, she pointed at the Care Report and stated it was not cut it was dislodged. She [Resident #1] did not have any wounds and she did not have a nephrostomy tube. She said the resident had a BIMS (Brief Interview for Mental Status) score was 12, which indicated mildly impaired cognition. The DON was unaware if an incident report was performed related to Resident #1 requiring a transfer to the hospital for a higher level or care. A review of a progress note dated 01/17/2023 at 10:50 a.m. revealed, Note Text: Social Service Director (SSD), met with pt. to complete SS (social service) evaluation, BIMS, Pt. was alert and oriented x 4 and was in a talkative mood as evidenced by stating she just celebrated her birthday. (Oriented x 4 meaning; someone who is alert and oriented to person, place, time, and event). On 03/14/2023 at 2:15 p.m., the DON said she was unable to locate an incident report for Resident #1 related to her transfer to the hospital on 01/18/2023. A review of the Agency for Health Care Administration form 5000-3008 dated 01/11/2023 revealed, Medical condition - Primary diagnosis: abdominal (abd) wall cellulitis jejunostomy (J)-tube infection, cholelithiasis. Comments: Flush cholecystectomy (chole) drain with 10 ml normal saline (NS) every 8 hours (8QH). Nutritional/ Hydration Supplements clear, ensure 4/day. A review of the treatment administration record (TAR) revealed no physician orders to monitor the biliary or jejunostomy sites, no orders for dressing changes, no orders for flushing the chole drain with normal saline every 8 hours, or monitoring the output of the chole drainage. On 3/14/2023 at 2:59 p.m., a phone interview was conducted with Staff E, Registered Nurse (RN). She said she recalled Resident #1 was alert and oriented x 3. She said Resident #1 had put on her call light and asked to have her dressing changed to the J- tube and change the other one. Staff E said the tubing was taped down to her stomach. When she went to pull it off, everything just came right out into my hand. She said I had no idea it came dislodged. Staff E confirmed there was no order in place for the dressing change. Staff E stated She [Resident #1] told me she wanted it changed because it smelled. Staff E described the dressing to the biliary site as brown in color and referred to it as old, stained blood, that was very sticky when touched. She confirmed the dressing contained a foul odor and stated, It hadn't been changed in a long time. She went on to say the J-tube dressing was saturated with stomach contents from the insertion site stating, it was green in color. Staff E stated, I have worked with biliary tubes before. Normally you just empty it and change the dressing. Normally it doesn't have a dressing on it but Resident #1 had one in place. She said she was taught if the dressing smelled and had blood on it, it needed to be changed. Staff E stated, it can harm the skin if it's not changed. She went on to say the collection bag needed to be emptied when it was full. She said, You just need to keep the line open to keep it flowing. On 03/14/2023 at 4:00 p.m., an interview was conducted with the DON. She was unable to find a policy for the care and services of a J-tube or biliary tube. The DON said they had what were called batch orders in the computer program they used. She said it had included dressing changes and monitoring of the tube site. She said the batch orders needed a physician's order to initiate. The DON said Resident #1's admission orders did not indicate dressing changes. On 3/15/2023 at 9:15 a.m., an interview was conducted with the DON. She confirmed Resident #1's medical record did not contain an Admission data collection assessment that would reflect the j tube or biliary tube sites. She was unable to provide a skin assessment during Resident #1's seven day stay at the facility. The DON stated, the admission nurse no longer works at the facility. She indicated it was the admission nurse' responsibility to perform the assessment. The DON was informed of the omitted dressing changes to the biliary and J-tube sites and the ordered flushes. On 03/15/2023 at 11:00 a.m., the DON was unable to provide a facility procedure on the care and services related to surgical drains. She stated, we follow Lippincott and provided a copy of Hepatic Billiard and Pancreatic Disorders chapter 19 page 736, undated. On page 737, Nursing Interventions Restoring Normal Fluid Volume 5. Observe and record amount of billiard tube drainage, if applicable. Patient Education and Health Maintenance 1. Instruct patient in care of tubes or catheters that may be in place at discharge. a. Observe for bleeding or drainage around insertion site. B. Replace dressing per facility protocol. c. Report change or decrease in drainage. On 03/15/2023 at 2:47 p.m., a phone interview was conducted with the facility's Medical Director (MD) who confirmed he remembered Resident #1. He confirmed she was admitted with a biliary tube and drainage system in place. He confirmed he was aware the biliary tube became dislodged and needed to be replaced. The MD indicated he was unaware the facility was not monitoring the biliary system as best practice would indicate. The MD stated, surgical sites are to be monitored, including dressing changes. And if there are no orders on admission the faciltiy needs to call for orders. The MD was informed of hospital admission orders to flush the biliary tubing every 8 hours. The order for the flushes were never transcribed nor performed during her admission of seven days. The Physician confirmed it was his expectation orders were followed. 2. A review of Nutrition Evaluation Comprehensive assessment for Resident #1 dated 01/16/2023 revealed, the most recent weight (wt.) and height (ht.) was omitted. Body mass index (BMI): 21.7, Usual Body Weight (UBW) 100 lb, Ideal Body Weight 105 lb. Diet Order: clear liquids. Comments: Resident is status post (s/p) hospitalization due to (d/t) abdominal wall cellulitis. Reports she is able to drink/have clear liquids without any GI symptoms. Aware of restrictions and Tube Feeding (TF) formulary. Unsure of UBW but reports she had gained weight and is into the 100's. Hospital wt.115 lbs. and ht.61 (5 feet) used to determine BMI and nutritional needs. Adjusted (Adj) BMI 22.8. Has TF regimen via j tube running for 12 hours/day. No pressure injuries noted. Tube Feeding order: Vivonex running at 35 milliliters per hour (ml/hr) for a total of 420 ml infused. Nutrition Intervention/ Monitoring/ Evaluation Change: continue current TF regimen, add Boost Breeze TID (three times per day) and prostate 30 ml for additional kcal/protein. On 03/15/2023 at 10:00 a.m., an interview was conducted with the Registered Dietitian (RD) as she recalled Resident #1, she stated she had been at the facility for a short period of time. The RD confirmed Resident #1 was able to answer all of her questions and was able to tell her stuff. She denied the resident had informed her of any concerns related to not receiving her supplements or enteral feedings. The RD confirmed Resident #1's admission orders were not transcribed into medication administration record accurately until 01/17/2023. She confirmed she had clarified the orders on 01/16/2023. She was unaware why the original order was not entered until 01/15/2023 at 12:30 p.m. when the resident was admitted on [DATE]. The RD reviewed the transcription of the order written on 01/15/2023, enteral feed orders every shift ADMIN VIA J-TUBE FOR 12 HRS UP AT 8A DWN 8P. She confirmed the transcription did not indicate what type of formula to administer, the rate of delivery, or the total volume that was needed. The RD confirmed she was unaware how much enteral feeding formula the resident was administered during her first twenty-four hours at the facility. The RD was unaware of the omission of the enteral feeding order on 01/16/2023 evening and night and on 01/19/2023 evening. The RD confirmed she had used Resident #1's hospital weight for the Nutrition Evaluation Comprehensive assessment that reflected 115 pounds. She said the facility did not weight the resident until 01/19/2023 that reflected 98.8 pounds. The RD said it was her expectation that a resident be weighed within 24 hours after admission. She did not know why there had been a five-day delay in obtaining her weight. The RD said she had identified on 01/16/2023 Resident #1 needed additional supplementation. She said she had ordered the boost breeze and pro-stat for additional calories. The RD was asked to look at the Agency for Health Care Administration Form 5000-3008, she indicated it was the first time she had seen the order for clear, ensure 4/day. She said the Boost Breeze was most appropriate and was equivalent to Ensure. The RD confirmed there had been a five-day delay in starting the boost breeze supplement. She said she had assumed it was not in the building until 01/19/2023. When asked the RD stated, Resident #1 had not lost weight since her admission. 3. On 3/13/2023 at 9:45 a.m., Resident #4 was observed lying in bed and made eye contact with verbal stimulation. She nodded her head in yes gesture when asked to be approached. She appeared comfortable and in no distress. On the left side of the bed a tube feeding machine was present and running at 55 cc hour. On 3/13/2023 at 10:15 a.m., Resident #4 was observed sitting up in a chair and smiled slightly when approached. The feeding machine continued to run at 55 ml per hour. The tubing that was attached to the machine was noted lying on the floor in a puddle of feeding formula. On 3/13/2023 at 10:20 a.m., Staff B Registered Nurse (RN), Unit Manager entered the bedroom. She confirmed she was present and assisted during Resident #4's transfer to the chair, stating a two person Hoyer lift. She said she had stopped the tube feeding machine prior to the transfer. Staff B said she had disconnected the tube from her g-tube site but she did not reconnect the tube. She said she was summoned by another staff member and had to leave the bedroom. She indicated she was unaware of the tubing on the floor. Staff B assisted with the observation of the percutaneous endoscopic gastrostomy (PEG) tube site that contained a retention disc (used to stabilize indwelling catheters). The retention disc was lifted slightly and revealed Resident #4's peri-stoma was bright red in color, from 4 to 6 o'clock reflected an open area with active red bloody drainage. Staff B confirmed the observation at the time (photographic evidence obtained). A review of Resident #4's treatment administration record (TAR) of physician orders dated 08/03/2023 at 4:24 p.m. (1624) revealed, Cleanse PEG tube site with normal saline (NS) as well as needed (PRN) every evening shift. A fourteen day look back reflected omitted documentation on 03/02/2023, 03/03/2023, 03/04/2023, 03/05/2023, 03/06/2023, 03/09/2023, 03/10/2023, and on 03/12/2023. On 3/14/2023 at 315 p.m., an interview was conducted with the DON. She said she was informed by the nurse that Resident #4's skin was open at the peri-stoma site. The DON indicated she was unaware of the omitted documentation in the resident TAR that reflected care was not provided to the PEG tube site for eight days. Nursing Progress notes dated 03/14/2023 at 4:28 p.m. (16:28) read as follows, Sister here at bedside made aware resident has a treatment order to peg tube site, related to reddened at site, small, opened area stoma. On 03/15/2023 at 2:47 p.m., a phone interview was conducted with the Medical Director (MD). He confirmed he knew Resident # 4 and was informed of the omitted documentation related to monitoring of her gastroesophageal site. The Physician was informed on 03/14/2023 that an observation of Resident #4's g-tube site revealed an open area under the disc The physician said he would be having an ad hoc meeting with the facility to discuss the concerns. On 3/14/2023 10:35 a.m., Resident #5 was observed lying in bed and was receptive to an observation alongside Staff C, RN, Unit Manager. Resident #5's PEG tube site bumper was slightly lifted which revealed a moderate amount of tan to brown colored stringy drainage and a moderate amount of scattered dried chunks of dark brown residual. Staff C stated, it needs to be cleaned. A review of Resident # 5's Admission Record form indicated she had resided at the facility for less than a month. Diagnoses listed on the form included dysphagia following unspecified cerebrovascular disease and gastrostomy status. There were no physician orders related to providing care or monitoring the G-tube site., Journal of Wound, Ostomy and Continence Nursing. Assess the stoma and peristomal skin daily for signs of inflammation, infection, pressure injury, bruises, and hypergranulation tissue. Document results of assessment and treatment used to manage stomal or peristomal complications. Affix a dressing under the exterior bumper, and replace it when necessary, such as with persistent leakage of fluid around the stoma, to prevent moisture-associated skin damage to the peristomal skin.https://www.nursingcenter.com/cearticle?an=00152192-201807000-00007#P119. Review of policy titled Abuse Prevention Program dated: August 2022. POLICY: The facility has designated and implemented process, which strive to reduce the risk of abuse, neglect, exploitation, mistreatment and misappropriation. Definitions: Neglect Failure of the facility, its employees or service providers to provide good and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress. Review of the policy titled STANDARD Topic; Physician Orders revealed the Policy Statement: At the time each resident is admitted , the facility will have physician orders for their immediate care. Physician orders will be dated and signed at next physician visit. Under the section entitled Procedure, point #4: Intravenous, Parenteral or enteral nutrition therapy orders will include the following required components: a. Fluid b. Amount c. Flow Rate d. Pump e. Flush orders Additionally, a separate order to be obtained for dressing changes for this therapy, if required. Medications that require monitoring will need to be entered into the electronic medical record. Point #15: Review orders from a physician other than the attending(specialist, consulting physician, etc. ) with the attending physician prior to implementation unless the attending physician has given previous written direction to accept the specialist/consultant order(s). Daily Order Compliance Process (Red Lining) The night shift nurses will verify orders received within the last 24 hours has been transcribed into the electronic record. The nurse will review each hard chart for new orders and compare to the electronic order listing report to ensure each written order has been entered into the electronic medical record. If a written physicians order if found on the chart and not on the order listing, transcribe the order and notify the resident/representative. Medication/Treatment variance may be completed if needed with physician notification.

Based on interviews with the Nursing Home Administrator, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident, the resident's family member, attending Physician staff and review of the of the facility's policies and the resident's medical record, the facility failed to thoroughly investigate the immediate cause and events leading up the an elopement for one (Resident #5) of four residents reviewed. Resident #5 was diagnosed with [REDACTED]. The resident had a history of [REDACTED]. She was refusing to take physician ordered medications that included [MEDICAL CONDITION] medication for depression and Paranoid [MEDICAL CONDITION] and an anticoagulant (blood thinner) for [MEDICAL CONDITION] Fibrillation (defined by the American Heart Association as a quivering or irregular heartbeat, 'arrhythmia' that can lead to blood clots, stroke, heart failure, and other-related complications). She recently had a syncopal episode (loss of consciousness) but refused to go to the hospital. On 7/13/2018, the resident's physician determined that the resident did not have the capacity to make health care decisions for herself or provide informed consent for medical treatment. On 9/15/19 between 11:45 a.m. and 12:15 p.m. the resident left the facility without the staff's knowledge, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, passed a wooded lot and out of sight of the facility. The resident was found standing in the grass between the street and the sidewalk by a staff member that was driving back from lunch. The Nursing Home Administrator (NHA) and the Director of Nurses (DON) were notified of the elopement but did not come into the facility until the following day to investigate or ensure that all residents in the facility were safe. After the elopement, the facility failed to thoroughly investigate and assess all the risk factors that placed the resident in an unsafe situation and at risk for harm and/or injury. This resulted in findings of Immediate Jeopardy that began on 9/15/2019 and was removed on 10/3/2019. Findings Included On 10/1/19 at 2:00 p.m., an interview was conducted with the Director of Nurses (DON), Risk Manager Specialist (RMS), and the Unit Manager (UM) regarding elopements. The DON said there was one resident, Resident #5, that went out of the facility, but it was not an elopement. She said the resident took her cell phone outside the building to call her daughter because she was worried that her daughter had not been to see her for a while. The RMS said the resident went out to the side walk in front of the facility and turned right. The resident was found down the street in front of an Assisted Living Facility. The RMS said Staff in the facility did not see her leave the facility. A staff member driving back from lunch saw the resident and brought her back to the facility. She said, the resident was assessed and found to be free of injury. When asked why the facility did not treat this incident as an elopement, the RMS said that the resident did not have history of elopement, she had a Leave of Absence (LOA) order from the physician, and the resident said she was safe because she walked down the middle of the sidewalk and had her cell phone with her. The RMS said the resident was assessed by therapy and was found to be safe because she knew when and how to cross the street. Again, the DON and the RMS verified that the facility did not consider the event to be an elopement. On 10/1/19 at 2:15 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the elopement. He said the event was not considered to be an elopement because the resident said she was safe, and she had her cell phone with her. He said the resident had a physician's orders [REDACTED]. (Review of the LOA order read as follows: (MONTH) go LOA with Escort with meds. Ordered 9/4/19). The NHA was asked if he was comfortable with the fact that the resident left the facility without the staff knowing about it, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, and was found down the street by a staff member coming back from lunch. He said he was uncomfortable that she left the building without signing out, but because the resident said she was safe and had her cell phone with her he was not uncomfortable about her leaving the facility. According to the Climatological Report (Daily) dated (MONTH) 16th, 2019 by the National Weather Service revealed on (MONTH) 15th, 2019 in the St. Petersburg, Florida area the temperature high for the day was 88 degrees Fahrenheit and the temperature low overnight from 8:00 p.m. to 8:00 a.m. was 79 degrees Fahrenheit. In the Tampa area the relative humidity averaged 74% on (MONTH) 15th, 2019. Review of the heat index from the National Weather Service revealed with a high of 88 degrees Fahrenheit and an average relative humidity of 74% the temperature outside felt as if it was 100 degrees. The National Weather Service indicated extreme caution with the likelihood of heat disorders with prolonged exposure or strenuous activity. On 10/1/19 at 3:50 p.m. and interview was conducted with the DON and NH[NAME] The DON and the NHA confirmed the policy named Elopement Management that was undated was their only elopement policy. The NHA stated they also follow The Tree to make decisions on whether or not an elopement has occurred. The DON and the NHA were asked according to The Tree did a resident/patient leave the premises or a safe area without authorization and/or necessary supervision? The DON and the NHA stated Yes. The DON and the NHA were asked was the resident at risk for harm or injury? The DON and the NHA stated No. The DON was asked if the resident was a fall risk. The DON stated, No. The DON was asked to pull up the resident's care plan and the DON said before pulling up the care plan that the resident was at risk for falls only because she was on [MEDICAL CONDITION] medications and because of their side effects. The DON said everyone on [MEDICAL CONDITION] was at risk for falls. The DON was asked since the resident was taking [MEDICAL CONDITION] medications, which puts her at risk for falls, is she a fall risk? The DON said, well, we are in the process for redoing all the resident's care plans because they are not accurate. We started that on 9/27/19 with a target date of completion by two weeks. The DON then read the resident's fall risk care plan out loud. She said, the resident was at risk for falls or fall related injury because of gait/balance problems, psychoactive drug use, and she had a slow steady gait. She required 1 person assist and cues for assistive device/walker. The DON said, That's not right because she does not use a walker anymore. She could out walk me. The NHA said she hasn't had a fall since I've been here. The DON nodded her head and said me either. The NHA said we asked therapy to do a safety screening on her and speech evaluated her. The NHA was asked why speech evaluated her related to this incident. He said well I'm not exactly sure what they do we just asked for a safety evaluation. The NHA continued to say the resident was always walking but typically she walked towards the dining room not the front desk area. He stated, I've never seen her go past my office. She was also far away from the road when we did the measurements. The NHA was asked who did the measurements and he said, I can't remember exactly but we took a measurement from where she was standing when she was found. The DON said sometimes you'll ask her if you can sit next to her on her bed, but she won't let you because she's paranoid at times she has [MEDICAL CONDITION]. The NHA stated, Because of this incident we educated all of our staff except a couple of PRN staff that don't come here anymore or are on leave of absence. We even threw in some code silver drills just because. The DON said, prior to the resident leaving the facility alone, she was assessed on the admission assessment and determined not to be an elopement risk. She said the resident was assessed after she left the facility unattended and determined to be an elopement risk. The DON was asked to show her elopement risk assessment and the DON looked at the administrator and said, Is that the BIMS score? The NHA did not answer her question. The DON then said, well there's not an actual elopement risk assessment we just care planned her and put a wander-guard on her. We just met with the Interdisciplinary Team (IDT) and decided she was an elopement risk. The NHA and the DON were asked, So given her risk for falls, her history of paranoid [MEDICAL CONDITION], dementia, leaving the building, walking down the street and or any other risk factors, did you feel the resident was at risk for injury or harm? The NHA and the DON both stated, No. Both the DON and NHA said the incident was not reported to any oversight agencies. After the interview, the falls care plan was reviewed and revealed that during the interview with the DON and NHA, the DON failed to read the care plan in its entirety. She omitted that the resident was at risk for falls or fall related injury related to a previous fall. The fall care plan read as follows: At risk for falls or fall related to injury because of previous fall, gait/balance problems, psychoactive drug use. She has a slow steady gait. Date initiated 1/11/19. Revision on: 9/16/19. A review of the facility's policy for Elopement-Overview 6.1.1 (Undated) was conducted and read as follow. Overview: The facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The elopement Prevention and Management program is an interdisciplinary process designed to reduce the risks of elopement while maximizing independence. The interdisciplinary team, which includes the resident/patient and family, designs and develops the least restrictive interventions to meet the individualized needs and goals of our residents/patients. Guidelines: 1. Complete admission data collection application. 2. Review and evaluate data. 3. Develop individualized interventions and communicate to staff. 4. Provide staff training and resident/patient and family education. Review Sign-out guidelines with the resident/responsible party on admission and quarterly. 5. Refer to the Resident/Patient Leave of Absence guidelines if: a. The cognitively intact resident/patient leaves independently for an outing (per physician's orders [REDACTED].>b. A family member/friend takes the cognitively impaired or cognitively intact resident/patient from the facility for an outing (per physician's orders [REDACTED]. 6. Review and revise Interdisciplinary Plan of Care as needed. 7. Initiate the Missing Resident/Patient Action Plan if unable to locate a resident/patient. 8. Re-evaluate resident/patient if elopement is unsuccessfully or successfully attempted. 9. Review and revise Interdisciplinary Plan of Care as needed. A review of the facility's policy for Elopement Management 6.4.1, undated, was conducted and read as follows. Overview: The interdisciplinary team will re-evaluate cognitively and/or psychologically impaired resident/patients who have attempted, unsuccessfully or successfully, to leave the facility with staff knowledge. With assistance of the resident/patient and family, individualized interventions will be developed and initiated to manager the elopement behavior. Guidelines: 1. Determine the following: a. Was the resident/patient trying to leave the facility? b. If yes, ask the resident/patient where and why they were trying to go. 2. Re-evaluate data as applicable which may, but are not limited to, the following: admitted collection and initial plan of care. Monthly, return and PRN data collection. Social Service assessment/discharge evaluation. Psychosocial history and assessment (Activities). 3. Determine if there is a pattern to the exit seeking behavior (i.e., exit seeking behavior occurs at specific times). 4. Evaluate the risk factors identified from the data collected. 5. Include resident/patient/family in development of the Plan of Care. 6. Monitor whereabouts of the at-risk resident/patient during rounds. 7. Schedule an Interdisciplinary Plan of Care meeting or (resent at the next scheduled Interdisciplinary Plan of Care and Standards of Care meeting. 8. Review and revise individualized intervention that may prevent further elopement attempts including, but not limited to the following: Re-evaluate effectiveness of activities. Develop a structed schedule. Involve recreational activities. Involve in productive daily activities such as folding laundry, cooking class, etc. Modify the environment to make it more structured/home-like. Provide activities in the evening for residents/patients with 'sundowning behavior. Redirect and reassure. 9. Discuss revised interventions with the resident/patient and responsible party and provide education as needed. 10. Communicate interventions to staff and provide training as needed. 11. Evaluate and document effectiveness of revised interdisciplinary interventions. 12. Review and Revise Plan of Care needed. A review of the facility's Elopement Decision Tree: Determination of Required Reporting (FL) Read as follows: Did a resident /patient leave the premises or a safe area without authorization and/or necessary supervision and was the resident at risk for harm or injury? If No, then Stop here; this is not an elopement. If Yes, then Is the resident/patient identified as at risk for elopement? If Yes, then Were appropriate interventions in place? If Yes, then Initiate new interventions. Update care plan. Communicate with family. File 15-day report. If No, then File Immediate/5 day/15-day reports. Update interventions. Communicate with family. If Unknown, then File Immediate/5 day/15-day reports. Update interventions. Communicate with family. Did a resident/patient leave the premises or a safe area without authorization and/or necessary supervision and was the resident at risk for harm or injury? If Yes, then Is the resident/patient identified as at risk for elopement? If No, then Are assessments accurate? If Yes, then Assess for change in condition. Initiate interventions. Communicate with family. File 15-day report. On 10/3/19 at 11:44 a.m. a telephone interview was conducted with Staff B Certified Nurse's Assistant (CNA) who found the resident outside and away from the facility. She said she was coming back from lunch, going south on 31st street towards the facility, when she saw what she thought may be a resident walking away from the facility down the street on the sidewalk. She said, at that time of day the traffic was heavy on the street. She pulled into the facility parking lot and flagged down a co-worker that was also coming back from lunch. She said she told her co-worker what she saw and got into the co-worker's vehicle to go get the resident. She said when they got to the resident, she was standing at the second entrance to an Assisted Living Facility. She was standing in the grass, not on the sidewalk, between the street and the sidewalk. She said the resident had a worried look on her face as if she was deciding what to do next. Staff B said, as her co-worker turned into the driveway, she got out of the vehicle before it stopped and called the resident's name. She said she knew the resident because she had worked with her before but said the resident was not currently on her assignment. She called the facility to inform them that the resident was found down the street and that they were returning to the facility. She said the resident responded to her name and when the CNA asked her where she was going, she said she was going to find her daughter and wanted the CNA to go with her. The CNA explained that they had to go back to the facility. The resident allowed her to turn her around and hold her hand. She said the resident held her hand all the way back to the facility. She said the resident told her that she had gone out the front door of the facility to go find her daughter. On 10/2/19 11:28 a.m., an interview was conducted with Staff C (CNA) who assisted with finding the resident away from the facility. She said, I was on my way back from lunch. I was parking my car in the front parking lot of the facility. I saw Staff B walking towards my car by the entrance. She was waving me down. She got in my car and said I think a resident got out. We need to go down and see who it is. We went together in my car and as we were turning to the right, we saw the resident. We drove to her and I parked my car in the Assisted Living Facility (ALF) parking lot at the second entrance. She was on the side walk by the second entrance of the ALF, so I parked my car. We got out and asked her if she was okay and she was like yeah, I'm fine. I looked down and said oh you have your phone with you. She said, yeah, she was looking for her daughter and asked us if we wanted to go with her. So, I told Staff B she can't get in my car you have to walk her back. So, Staff B started talking to her and getting her back towards the building. I don't know what they were talking about because I got back into my car to park it. It was probably about 12 something. She walked back with no resistance that I know of. It was sunny like today, it was hot that day. She was walking like how she normally walks like she was roaming. When I got back into the building she was back in her room. I probably left for lunch around 11:30ish. When I left no one was looking for the resident at all. A review of the Interview Follow-up Questions (Undated) related to the written statement provided by Staff C revealed that one of the questions was, Was she wearing her glasses. The answer was No. The document was signed (Undated) by Staff C. On 10/2/19 at 12:04 p.m., a telephone interview was conducted with the resident's Primary Care Physician (PCP). He verified that he took care of Resident #5 and the majority of the residents at the facility. He stated that he truly did not recall the resident leaving the facility and walking down the sidewalk alone. He said his nurse practitioner might know and agreed with his order for may go LOA with escort. On 10/3/19 at 9:49 a.m., a telephone interview was conducted with the PCP's Advanced Practice Registered Nurse (APRN). The APRN stated she followed Resident #5 and said she was very familiar with her. The APRN stated, I'm not sure if they told me about her leaving the facility alone but they might have told me about it. I don't have my notes on me. She said, We have been working very closely with her. She said, psych is following her but she's not responding to anyone. She's not caring for herself like she used to and she's not eating like she used too. We even sent her out to the hospital at one point, but they said nothing was wrong with her. Psych recommended medications but she refuses her medications and those medications take a good three weeks to kick in. She has not responded to anyone to let us know what's wrong. They usually call me for every little incident I couldn't image they wouldn't have told me. The APRN was asked if the resident was safe to leave the building without an escort and she said, No, no, no she would not be safe no. When I'm at the facility she will respond to my commands but I'm not there every day so as soon as I leave, she won't listen to anyone. On 10/3/19 at 10:13 a.m. an interview was conducted with the psychiatric services APRN. She stated she was familiar with the resident and stated she recalled when she left the facility without an escort. She was asked if the resident was safe to do so and she stated, No she's not safe to leave by herself. She's demented and has a lot of paranoia, yeah, I don't even know how she got out but no she's not safe to go out alone. She said, because of her paranoia and her dementia she does not want to take her medication. Staff is really good about positive reinforcement to take her meds. The resident she kept thinking staff was putting stuff in her food and giving her medications. Now her daughter has been coming in, in the afternoons to help her take her medications. That's been going on for about a month or so. At 10:23 a.m., the APRN called back and said she remembered the resident saying something about how she, doesn't know why she walked outside. On 10/4/19 10:02 a.m., a telephone interview was conducted with the on-call physician on 9/15/19. He stated he had never been to the facility and was not familiar with the resident. He stated I was given a call when I was on that day from a nurse from the facility. It was reported that the patient went out of the facility. She was outside and she decided to come back in willingly. He said when she came back in, she was in good state of mind because I asked if they assessed her. They said she was not confused or disoriented, and she had no physical injuries. I told them they should keep a close eye on her, so she doesn't go back outside alone again. He said, No she was not safe to go outside by herself because we didn't know she wanted to go outside. I told them to keep a close eye on her after she went outside because I did not want her going back outside alone. And the fact that they called me means she was not authorized to go outside alone in the first place. He said, the resident Was mentally and physically okay so there was no further intervention that was needed from me at that point. On 10/3/19 at 1:44 p.m. an interview was conducted with the resident's daughter. She said she was initially led to believe that the resident was wandering around inside the facility looking for her. She said she had been sick and missed a couple days of visiting her mother. She said she came to visit the next day. She said her mother did not show any signs of distress and seems her normal self. She said the NHA told her that the resident was found outside of the facility on the sidewalk. She said she was shocked but didn't make a big deal about it. When asked if she felt that her mother was safe to be outside of the facility by herself, she said, No due to her memory issues. She said the resident needs glasses to see and does not always wear the glasses and may not be able to see where she is going. She said the resident is weak and may collapse if she walks too far. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Evaluation of Resident's Capacity to make Health Care Decisions or Provide Informed Consent indicated that, on 7/13/18, the resident's physician determined that the resident was unable to make health care decisions for herself or provide informed consent for medical treatment. The determination was based on the physician's examination that included, Review of all medical records in the patient chart, including hospital records, laboratory reports, x-rays and consultant's reports to confirm capacity to make health care decisions or provide informed consent. A review of the Primary Care Physician notes read as follows. 7/21/2019: Patient is a 75-year female being seen for follow up of multiple medical problems. She utilizes a walker for ambulation. She said, My legs are a little weak. She has diminished her eating intake lately. As per staff, patient is eating about 25 % of her meals. 7/22/2019: Resident has had a change in mentation. Her affect is flat. Referral provided for her to see psych services. She is using a walker for ambulation. 8/12/2019: Patient is seen in room, she is lying under her blanket and refusing to remove it. Allows for examination with covers, states she is fine, denies pain at this time. Patient continues to be seen by psych. 9/4/2019: Reason for visit: Called to see patient who is refusing medications. Patient has been refusing all medications especially in the morning. I have asked patient if she has been taking medications. She responded adamantly she was taking all the medications. She responded adamantly she was taking all the medications and the nurses were 'lying to you'. In addition, patient continues to have very poor oral intake. Family member still refuses to have the patient receive an appetite stimulant. A review of the Psych notes read as follows: 7/11/2019: Patient continues to refuse medication and display paranoid delusions. She states, I'm not taking my medications because I don't know what they are putting in it. Plan: Increase [MEDICATION NAME] to 50 mg QHS. 8/5/2019: Patient last seen on 7/23/2019 at which time she was started on [MEDICATION NAME] and tapered off [MEDICATION NAME]. Patient states she is tolerating new medication well. 8/12/2019: Patient seen for a wellness check requested by staff due to recent behavioral changes and agitation. Staff reports patient has been refusing medications and threatened to hurt a staff member. Patient states her mood is good and that she has been taking her medications every day. Denies threatening a staff member. 8/19/2019: Patient is seen for a wellness check requested by staff due to refusal of medication, paranoia, and agitation. Staff reports patient has been paranoid with food and medications. Staff report that patient thinks people are trying to poison her food or that they are giving her the wrong medications. Resident said, I have been taking medication. Patient denies mood swings, depression agitation, anxiety, and auditory/visual hallucinations. Plan: [MEDICATION NAME] 0.5mg Intramuscular (IM) at bedtime for 3 days. 9/5/2019: Seen for follow up requested by staff due to refusing medications and increased paranoia. Patient states her mood is Okay. She states she does not know why she refuses her medications. Staff report that the patient is resistant and paranoid when staff attempt to give pills and meals due to patient thinking that staff is trying to poison her. 9/16/2019: Seen for wellness check requested by staff due to elopement. Staff reports patient was seen walking outside. She states, I don't know what I was doing outside. I was just walking. Risks of walking outside alone were discussed with patient at which time patient verbalized understanding of comments in full. Staff deny other behavioral disturbances. A review of the nurse's notes read as follows: 9/4/19 7:41 p.m. eINTERACT SBAR (Situation Background Assessment Recommendation): Change in condition: Loss of Consciousness ([MEDICAL CONDITION]). 9/4/19 9:52 p.m. Resident had a syncopal episode, she was aroused via sternal rub. Blood Pressure (BP) / Heart Rate (HR) was checked (142/87, 60) Emergency Medical Services (EMS) notified and upon assessment done by paramedics, resident was in [MEDICAL CONDITION] Fibrillation and daughter/resident refused to be transferred to the hospital for further evaluation. On call MD notified and await further orders. 9/5/19 11:48 a.m. Spoke with Dr. regarding resident's episode of [MEDICAL CONDITION] last night and that resident's daughter did not wish for her to go to the hospital. Meds reviewed with the doctor and vital signs of BP 123/58, Pulse 56, Respirations 20, Temperature 97.8 and Oxygen saturation 98% on room air. Order received for Electrocardiogram (EKG). 9/5/2019 11:42 p.m. The EKG was done with abnormal results received. Resident resting peacefully in bed, son at bedside visiting, resident denies pain or discomfort. No visible signs/symptoms or shortness of breath. Called placed to on - call Advanced Registered Nurse Practitioner (ARNP), she informed writer to call the ordering MD in AM with result, due to resident's history of [MEDICAL CONDITION]. Scheduled medications taken this shift by resident with much encouragement of son. 9/6/19 4:15 p.m. Continues to refuse medications, Medical Doctor (MD) aware and Power of Attorney (POA) notified. 9/7/19 4:10 p.m. Refused to take her morning medications. On call doctor informed. No new orders. 9/10/19 2:16 p.m. Resident alert with confusion, able to make needs known, denies pain this shift, no visible s/s of discomfort/distress. Offered meds, post blood pressure (BP), resident states, I will only take BP medication. Refused all other meds this shift. MD notified of refusal/family aware of same. 9/12/19 11:09 a.m. Resident refused her 9:00 a.m. medications offered on several occasions. Primary Care Physician (PCP) made aware. 9/13/19 11:56 a.m. Resident was offered on several occasions her 9:00 a.m. medications. Refuses stated, I already took my medications. PCP made aware. 9/15/19 3:17 p.m. Patient was found approximately 12:13 p.m. wondering outside from the premises found by Certified Nurse's Assistant (CNA) and assisted back into the facility and assessment made and there was no found injuries or active distress and vital signs are stable. Resident stated, I was looking for my daughter. I was on the sidewalk. Resident also had her cell phone in her hand. NHA, MD and family member was notified. Initiated close monitoring of 1:1, wander guard, and updated information inserted into elopement books. Patient was last seen by assigned CNA at 11:45 a.m. 9/15/19 5:17 p.m. Physician called back informed him condition no new orders noted and will continue to monitor patient with aide at the bedside on 1:1 as well as 15-minute checks for safety of patient. 9/16/19 3:15 p.m. Attempted to call resident daughter two times today. Both calls had no answer or call back. However, the unit manager called from her cell and the resident's daughter answered stating that she is aware of what happened and that her Mom only left looking for her because she had not been here to see her mom and typically, she normally sees her every day and her mom missed her. She states she will be in to see her mom today. 9/16/19 3:42 p.m. Resident remains on one to one supervision with CN[NAME] CNA states that the resident ate her meals today and did not allow her to assist with her care. Writer spoke with the resident who stated when asked that she was just going for a walk and writer encouraged her to ask someone to go with her next time. As the writer was leaving the resident's room she stated, They are lying on me I didn't go anywhere. Resident was seen by medical Advanced Registered Nurse Practitioner (ARNP) with orders for labs. Writer called and spoke with resident's daughter who stated that resident said she was coming to see her as she had been sick and was not in for 3 days when she is usually here every night. Daughter states that she will be in to see resident tonight. 9/18/19 7:44 a.m. Care plan/Interdisciplinary Team (IDT) note: The IDT met 9/17/19 about resident and decided that if the resident had a good night (displaying no maladaptive behaviors and signs of exit seeking) the 1:1 will be discontinued in the morning. Psych ARNP agreed. This writer confirms resident has not displayed any behaviors in the last 48 hours of exit seeking and therefore 1:1 has been removed. MD and daughter aware. 9/18/19 1:26 p.m. Resident placed on safety checks Q15 minutes until re-evaluated by the IDT. Q15 minute sheet to be completed each shift as well as task section of CNA plan of care shall be documented. MD and family aware. 9/20/19 2:57 p.m. SSD spoke with the resident's daughter/Health Care Proxy (HCP). Social Service Director (SSD) suggested room [ROOM NUMBER]. Resident daughter declined to allow the room change. She stated the resid

Based on interviews with the Nursing Home Administrator, the Director of Nursing, Assistant Director of Nursing, nursing staff, certified nursing staff, the resident, the resident's family member, attending Physician staff and review of the of the facility's policies and the resident's medical record, the facility failed to thoroughly investigate the immediate cause and events leading up the an elopement for one (Resident #5) of four residents reviewed. Resident #5 was diagnosed with [REDACTED]. The resident had a history of [REDACTED]. She was refusing to take physician ordered medications that included [MEDICAL CONDITION] medication for depression and Paranoid [MEDICAL CONDITION] and an anticoagulant (blood thinner) for [MEDICAL CONDITION] Fibrillation (defined by the American Heart Association as a quivering or irregular heartbeat, 'arrhythmia' that can lead to blood clots, stroke, heart failure, and other-related complications). She recently had a syncopal episode (loss of consciousness) but refused to go to the hospital. On 7/13/2018, the resident's physician determined that the resident did not have the capacity to make health care decisions for herself or provide informed consent for medical treatment. On 9/15/19 between 11:45 a.m. and 12:15 p.m. the resident left the facility without the staff's knowledge, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, passed a wooded lot and out of sight of the facility. The resident was found standing in the grass between the street and the sidewalk by a staff member that was driving back from lunch. The Nursing Home Administrator (NHA) and the Director of Nurses (DON) were notified of the elopement but did not come into the facility until the following day to investigate or ensure that all residents in the facility were safe. After the elopement, the facility failed to thoroughly investigate and assess all the risk factors that placed the resident in an unsafe situation and at risk for harm and/or injury. This resulted in findings of Immediate Jeopardy that began on 9/15/2019 and was removed on 10/3/2019. Findings Included On 10/1/19 at 2:00 p.m., an interview was conducted with the Director of Nurses (DON), Risk Manager Specialist (RMS), and the Unit Manager (UM) regarding elopements. The DON said there was one resident, Resident #5, that went out of the facility, but it was not an elopement. She said the resident took her cell phone outside the building to call her daughter because she was worried that her daughter had not been to see her for a while. The RMS said the resident went out to the side walk in front of the facility and turned right. The resident was found down the street in front of an Assisted Living Facility. The RMS said Staff in the facility did not see her leave the facility. A staff member driving back from lunch saw the resident and brought her back to the facility. She said, the resident was assessed and found to be free of injury. When asked why the facility did not treat this incident as an elopement, the RMS said that the resident did not have history of elopement, she had a Leave of Absence (LOA) order from the physician, and the resident said she was safe because she walked down the middle of the sidewalk and had her cell phone with her. The RMS said the resident was assessed by therapy and was found to be safe because she knew when and how to cross the street. Again, the DON and the RMS verified that the facility did not consider the event to be an elopement. On 10/1/19 at 2:15 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the elopement. He said the event was not considered to be an elopement because the resident said she was safe, and she had her cell phone with her. He said the resident had a physician's orders [REDACTED]. (Review of the LOA order read as follows: (MONTH) go LOA with Escort with meds. Ordered 9/4/19). The NHA was asked if he was comfortable with the fact that the resident left the facility without the staff knowing about it, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, and was found down the street by a staff member coming back from lunch. He said he was uncomfortable that she left the building without signing out, but because the resident said she was safe and had her cell phone with her he was not uncomfortable about her leaving the facility. According to the Climatological Report (Daily) dated (MONTH) 16th, 2019 by the National Weather Service revealed on (MONTH) 15th, 2019 in the St. Petersburg, Florida area the temperature high for the day was 88 degrees Fahrenheit and the temperature low overnight from 8:00 p.m. to 8:00 a.m. was 79 degrees Fahrenheit. In the Tampa area the relative humidity averaged 74% on (MONTH) 15th, 2019. Review of the heat index from the National Weather Service revealed with a high of 88 degrees Fahrenheit and an average relative humidity of 74% the temperature outside felt as if it was 100 degrees. The National Weather Service indicated extreme caution with the likelihood of heat disorders with prolonged exposure or strenuous activity. On 10/1/19 at 3:50 p.m. and interview was conducted with the DON and NH[NAME] The DON and the NHA confirmed the policy named Elopement Management that was undated was their only elopement policy. The NHA stated they also follow The Tree to make decisions on whether or not an elopement has occurred. The DON and the NHA were asked according to The Tree did a resident/patient leave the premises or a safe area without authorization and/or necessary supervision? The DON and the NHA stated Yes. The DON and the NHA were asked was the resident at risk for harm or injury? The DON and the NHA stated No. The DON was asked if the before pulling up the care plan that the resident was at risk for falls only because she was on [MEDICAL CONDITION] medicaresident was a fall risk. The DON stated, No. The DON was asked to pull up the resident's care plan and the DON said tions and because of their side effects. The DON said everyone on [MEDICAL CONDITION] was at risk for falls. The DON was asked since the resident was taking [MEDICAL CONDITION] medications, which puts her at risk for falls, is she a fall risk? The DON said, well, we are in the process for redoing all the resident's care plans because they are not accurate. We started that on 9/27/19 with a target date of completion by two weeks. The DON then read the resident's fall risk care plan out loud. She said, the resident was at risk for falls or fall related injury because of gait/balance problems, psychoactive drug use, and she had a slow steady gait. She required 1 person assist and cues for assistive device/walker. The DON said, That's not right because she does not use a walker anymore. She could out walk me. The NHA said she hasn't had a fall since I've been here. The DON nodded her head and said me either. The NHA said we asked therapy to do a safety screening on her and speech evaluated her. The NHA was asked why speech evaluated her related to this incident. He said well I'm not exactly sure what they do we just asked for a safety evaluation. The NHA continued to say the resident was always walking but typically she walked towards the dining room not the front desk area. He stated, I've never seen her go past my office. She was also far away from the road when we did the measurements. The NHA was asked who did the measurements and he said, I can't remember exactly but we took a measurement from where she was standing when she was found. The DON said sometimes you'll ask her if you can sit next to her on her bed, but she won't let you because she's paranoid at times she has [MEDICAL CONDITION]. The NHA stated, Because of this incident we educated all of our staff except a couple of PRN staff that don't come here anymore or are on leave of absence. We even threw in some code silver drills just because. The DON said, prior to the resident leaving the facility alone, she was assessed on the admission assessment and determined not to be an elopement risk. She said the resident was assessed after she left the facility unattended and determined to be an elopement risk. The DON was asked to show her elopement risk assessment and the DON looked at the administrator and said, Is that the BIMS score? The NHA did not answer her question. The DON then said, well there's not an actual elopement risk assessment we just care planned her and put a wander-guard on her. We just met with the Interdisciplinary Team (IDT) and decided she was an elopement risk. The NHA and the DON were asked, So given her risk for falls, her history of paranoid [MEDICAL CONDITION], dementia, leaving the building, walking down the street and or any other risk factors, did you feel the resident was at risk for injury or harm? The NHA and the DON both stated, No. Both the DON and NHA said the incident was not reported to any oversight agencies. After the interview, the falls care plan was reviewed and revealed that during the interview with the DON and NHA, the DON failed to read the care plan in its entirety. She omitted that the resident was at risk for falls or fall related injury related to a previous fall. The fall care plan read as follows: At risk for falls or fall related to injury because of previous fall, gait/balance problems, psychoactive drug use. She has a slow steady gait. Date initiated 1/11/19. Revision on: 9/16/19. A review of the facility's policy for Elopement-Overview 6.1.1 (Undated) was conducted and read as follow. Overview: The facility elopement definition is as follows: Elopement occurs when a resident leaves the premises or a safe area without authorization (i.e., an order for [REDACTED]. The elopement Prevention and Management program is an interdisciplinary process designed to reduce the risks of elopement while maximizing independence. The interdisciplinary team, which includes the resident/patient and family, designs and develops the least restrictive interventions to meet the individualized needs and goals of our residents/patients. Guidelines: 1. Complete admission data collection application. 2. Review and evaluate data. 3. Develop individualized interventions and communicate to staff. 4. Provide staff training and resident/patient and family education. Review Sign-out guidelines with the resident/responsible party on admission and quarterly. 5. Refer to the Resident/Patient Leave of Absence guidelines if: a. The cognitively intact resident/patient leaves independently for an outing (per physician's orders [REDACTED].>b. A family member/friend takes the cognitively impaired or cognitively intact resident/patient from the facility for an outing (per physician's orders [REDACTED]. 6. Review and revise Interdisciplinary Plan of Care as needed. 7. Initiate the Missing Resident/Patient Action Plan if unable to locate a resident/patient. 8. Re-evaluate resident/patient if elopement is unsuccessfully or successfully attempted. 9. Review and revise Interdisciplinary Plan of Care as needed. A review of the facility's policy for Elopement Management 6.4.1, undated, was conducted and read as follows. Overview: The interdisciplinary team will re-evaluate cognitively and/or psychologically impaired resident/patients who have attempted, unsuccessfully or successfully, to leave the facility with staff knowledge. With assistance of the resident/patient and family, individualized interventions will be developed and initiated to manager the elopement behavior. Guidelines: 1. Determine the following: a. Was the resident/patient trying to leave the facility? b. If yes, ask the resident/patient where and why they were trying to go. 2. Re-evaluate data as applicable which may, but are not limited to, the following: admitted collection and initial plan of care. Monthly, return and PRN data collection. Social Service assessment/discharge evaluation. Psychosocial history and assessment (Activities). 3. Determine if there is a pattern to the exit seeking behavior (i.e., exit seeking behavior occurs at specific times). 4. Evaluate the risk factors identified from the data collected. 5. Include resident/patient/family in development of the Plan of Care. 6. Monitor whereabouts of the at-risk resident/patient during rounds. 7. Schedule an Interdisciplinary Plan of Care meeting or (resent at the next scheduled Interdisciplinary Plan of Care and Standards of Care meeting. 8. Review and revise individualized intervention that may prevent further elopement attempts including, but not limited to the following: Re-evaluate effectiveness of activities. Develop a structured schedule. Involve recreational activities. Involve in productive daily activities such as folding laundry, cooking class, etc. Modify the environment to make it more structured/home-like. Provide activities in the evening for residents/patients with 'sundowning behavior. Redirect and reassure. 9. Discuss revised interventions with the resident/patient and responsible party and provide education as needed. 10. Communicate interventions to staff and provide training as needed. 11. Evaluate and document effectiveness of revised interdisciplinary interventions. 12. Review and Revise Plan of Care needed. A review of the facility's Elopement Decision Tree: Determination of Required Reporting (FL) Read as follows: Did a resident /patient leave the premises or a safe area without authorization and/or necessary supervision and was the resident at risk for harm or injury? If No, then Stop here; this is not an elopement. If Yes, then Is the resident/patient identified as at risk for elopement? If Yes, then Were appropriate interventions in place? If Yes, then Initiate new interventions. Update care plan. Communicate with family. File 15-day report. If No, then File Immediate/5 day/15-day reports. Update interventions. Communicate with family. If Unknown, then File Immediate/5 day/15-day reports. Update interventions. Communicate with family. Did a resident/patient leave the premises or a safe area without authorization and/or necessary supervision and was the resident at risk for harm or injury? If Yes, then Is the resident/patient identified as at risk for elopement? If No, then Are assessments accurate? If Yes, then Assess for change in condition. Initiate interventions. Communicate with family. File 15-day report. On 10/3/19 at 11:44 a.m. a telephone interview was conducted with Staff B Certified Nurse's Assistant (CNA) who found the resident outside and away from the facility. She said she was coming back from lunch, going south on 31st street towards the facility, when she saw what she thought may be a resident walking away from the facility down the street on the sidewalk. She said, at that time of day the traffic was heavy on the street. She pulled into the facility parking lot and flagged down a co-worker that was also coming back from lunch. She said she told her co-worker what she saw and got into the co-worker's vehicle to go get the resident. She said when they got to the resident, she was standing at the second entrance to an Assisted Living Facility. She was standing in the grass, not on the sidewalk, between the street and the sidewalk. She said the resident had a worried look on her face as if she was deciding what to do next. Staff B said, as her co-worker turned into the driveway, she got out of the vehicle before it stopped and called the resident's name. She said she knew the resident because she had worked with her before but said the resident was not currently on her assignment. She called the facility to inform them that the resident was found down the street and that they were returning to the facility. She said the resident responded to her name and when the CNA asked her where she was going, she said she was going to find her daughter and wanted the CNA to go with her. The CNA explained that they had to go back to the facility. The resident allowed her to turn her around and hold her hand. She said the resident held her hand all the way back to the facility. She said the resident told her that she had gone out the front door of the facility to go find her daughter. On 10/2/19 11:28 a.m., an interview was conducted with Staff C (CNA) who assisted with finding the resident away from the facility. She said, I was on my way back from lunch. I was parking my car in the front parking lot of the facility. I saw Staff B walking towards my car by the entrance. She was waving me down. She got in my car and said I think a resident got out. We need to go down and see who it is. We went together in my car and as we were turning to the right, we saw the resident. We drove to her and I parked my car in the Assisted Living Facility (ALF) parking lot at the second entrance. She was on the side walk by the second entrance of the ALF, so I parked my car. We got out and asked her if she was okay and she was like yeah, I'm fine. I looked down and said oh you have your phone with you. She said, yeah, she was looking for her daughter and asked us if we wanted to go with her. So, I told Staff B she can't get in my car you have to walk her back. So, Staff B started talking to her and getting her back towards the building. I don't know what they were talking about because I got back into my car to park it. It was probably about 12 something. She walked back with no resistance that I know of. It was sunny like today, it was hot that day. She was walking like how she normally walks like she was roaming. When I got back into the building she was back in her room. I probably left for lunch around 11:30ish. When I left no one was looking for the resident at all. A review of the Interview Follow-up Questions (Undated) related to the written statement provided by Staff C revealed that one of the questions was, Was she wearing her glasses. The answer was No. The document was signed (Undated) by Staff C. On 10/2/19 at 12:04 p.m., a telephone interview was conducted with the resident's Primary Care Physician (PCP). He verified that he took care of Resident #5 and the majority of the residents at the facility. He stated that he truly did not recall the resident leaving the facility and walking down the sidewalk alone. He said his nurse practitioner might know and agreed with his order for may go LOA with escort. On 10/3/19 at 9:49 a.m., a telephone interview was conducted with the PCP's Advanced Practice Registered Nurse (APRN). The APRN stated she followed Resident #5 and said she was very familiar with her. The APRN stated, I'm not sure if they told me about her leaving the facility alone but they might have told me about it. I don't have my notes on me. She said, We have been working very closely with her. She said, psych is following her but she's not responding to anyone. She's not caring for herself like she used to and she's not eating like she used too. We even sent her out to the hospital at one point, but they said nothing was wrong with her. Psych recommended medications but she refuses her medications and those medications take a good three weeks to kick in. She has not responded to anyone to let us know what's wrong. They usually call me for every little incident I couldn't image they wouldn't have told me. The APRN was asked if the resident was safe to leave the building without an escort and she said, No, no, no she would not be safe no. When I'm at the facility she will respond to my commands but I'm not there every day so as soon as I leave, she won't listen to anyone. On 10/3/19 at 10:13 a.m. an interview was conducted with the psychiatric services APRN. She stated she was familiar with the resident and stated she recalled when she left the facility without an escort. She was asked if the resident was safe to do so and she stated, No she's not safe to leave by herself. She's demented and has a lot of paranoia, yeah, I don't even know how she got out but no she's not safe to go out alone. She said, because of her paranoia and her dementia she does not want to take her medication. Staff is really good about positive reinforcement to take her meds. The resident she kept thinking staff was putting stuff in her food and giving her medications. Now her daughter has been coming in, in the afternoons to help her take her medications. That's been going on for about a month or so. At 10:23 a.m., the APRN called back and said she remembered the resident saying something about how she, doesn't know why she walked outside. On 10/4/19 10:02 a.m., a telephone interview was conducted with the on-call physician on 9/15/19. He stated he had never been to the facility and was not familiar with the resident. He stated I was given a call when I was on that day from a nurse from the facility. It was reported that the patient went out of the facility. She was outside and she decided to come back in willingly. He said when she came back in, she was in good state of mind because I asked if they assessed her. They said she was not confused or disoriented, and she had no physical injuries. I told them they should keep a close eye on her, so she doesn't go back outside alone again. He said, No she was not safe to go outside by herself because we didn't know she wanted to go outside. I told them to keep a close eye on her after she went outside because I did not want her going back outside alone. And the fact that they called me means she was not authorized to go outside alone in the first place. He said, the resident Was mentally and physically okay so there was no further intervention that was needed from me at that point. On 10/3/19 at 1:44 p.m. an interview was conducted with the resident's daughter. She said she was initially led to believe that the resident was wandering around inside the facility looking for her. She said she had been sick and missed a couple days of visiting her mother. She said she came to visit the next day. She said her mother did not show any signs of distress and seems her normal self. She said the NHA told her that the resident was found outside of the facility on the sidewalk. She said she was shocked but didn't make a big deal about it. When asked if she felt that her mother was safe to be outside of the facility by herself, she said, No due to her memory issues. She said the resident needs glasses to see and does not always wear the glasses and may not be able to see where she is going. She said the resident is weak and may collapse if she walks too far. Resident #5 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the Physician's Evaluation of Resident's Capacity to make Health Care Decisions or Provide Informed Consent indicated that, on 7/13/18, the resident's physician determined that the resident was unable to make health care decisions for herself or provide informed consent for medical treatment. The determination was based on the physician's examination that included, Review of all medical records in the patient chart, including hospital records, laboratory reports, x-rays and consultant's reports to confirm capacity to make health care decisions or provide informed consent. A review of the Primary Care Physician notes read as follows. 7/21/2019: Patient is a 75-year female being seen for follow up of multiple medical problems. She utilizes a walker for ambulation. She said, My legs are a little weak. She has diminished her eating intake lately. As per staff, patient is eating about 25 % of her meals. 7/22/2019: Resident has had a change in mentation. Her affect is flat. Referral provided for her to see psych services. She is using a walker for ambulation. 8/12/2019: Patient is seen in room, she is lying under her blanket and refusing to remove it. Allows for examination with covers, states she is fine, denies pain at this time. Patient continues to be seen by psych. 9/4/2019: Reason for visit: Called to see patient who is refusing medications. Patient has been refusing all medications especially in the morning. I have asked patient if she has been taking medications. She responded adamantly she was taking all the medications. She responded adamantly she was taking all the medications and the nurses were 'lying to you'. In addition, patient continues to have very poor oral intake. Family member still refuses to have the patient receive an appetite stimulant. A review of the Psych notes read as follows: 7/11/2019: Patient continues to refuse medication and display paranoid delusions. She states, I'm not taking my medications because I don't know what they are putting in it. Plan: Increase [MEDICATION NAME] to 50 mg QHS. 8/5/2019: Patient last seen on 7/23/2019 at which time she was started on [MEDICATION NAME] and tapered off [MEDICATION NAME]. Patient states she is tolerating new medication well. 8/12/2019: Patient seen for a wellness check requested by staff due to recent behavioral changes and agitation. Staff reports patient has been refusing medications and threatened to hurt a staff member. Patient states her mood is good and that she has been taking her medications every day. Denies threatening a staff member. 8/19/2019: Patient is seen for a wellness check requested by staff due to refusal of medication, paranoia, and agitation. Staff reports patient has been paranoid with food and medications. Staff report that patient thinks people are trying to poison her food or that they are giving her the wrong medications. Resident said, I have been taking medication. Patient denies mood swings, depression agitation, anxiety, and auditory/visual hallucinations. Plan: [MEDICATION NAME] 0.5mg Intramuscular (IM) at bedtime for 3 days. 9/5/2019: Seen for follow up requested by staff due to refusing medications and increased paranoia. Patient states her mood is Okay. She states she does not know why she refuses her medications. Staff report that the patient is resistant and paranoid when staff attempt to give pills and meals due to patient thinking that staff is trying to poison her. 9/16/2019: Seen for wellness check requested by staff due to elopement. Staff reports patient was seen walking outside. She states, I don't know what I was doing outside. I was just walking. Risks of walking outside alone were discussed with patient at which time patient verbalized understanding of comments in full. Staff deny other behavioral disturbances. A review of the nurse's notes read as follows: 9/4/19 7:41 p.m. eINTERACT SBAR (Situation Background Assessment Recommendation): Change in condition: Loss of Consciousness ([MEDICAL CONDITION]). 9/4/19 9:52 p.m. Resident had a syncopal episode, she was aroused via sternal rub. Blood Pressure (BP) / Heart Rate (HR) was checked (142/87, 60) Emergency Medical Services (EMS) notified and upon assessment done by paramedics, resident was in [MEDICAL CONDITION] Fibrillation and daughter/resident refused to be transferred to the hospital for further evaluation. On call MD notified and await further orders. 9/5/19 11:48 a.m. Spoke with Dr. regarding resident's episode of [MEDICAL CONDITION] last night and that resident's daughter did not wish for her to go to the hospital. Meds reviewed with the doctor and vital signs of BP 123/58, Pulse 56, Respirations 20, Temperature 97.8 and Oxygen saturation 98% on room air. Order received for Electrocardiogram (EKG). 9/5/2019 11:42 p.m. The EKG was done with abnormal results received. Resident resting peacefully in bed, son at bedside visiting, resident denies pain or discomfort. No visible signs/symptoms or shortness of breath. Called placed to on - call Advanced Registered Nurse Practitioner (ARNP), she informed writer to call the ordering MD in AM with result, due to resident's history of [MEDICAL CONDITION]. Scheduled medications taken this shift by resident with much encouragement of son. 9/6/19 4:15 p.m. Continues to refuse medications, Medical Doctor (MD) aware and Power of Attorney (POA) notified. 9/7/19 4:10 p.m. Refused to take her morning medications. On call doctor informed. No new orders. 9/10/19 2:16 p.m. Resident alert with confusion, able to make needs known, denies pain this shift, no visible s/s of discomfort/distress. Offered meds, post blood pressure (BP), resident states, I will only take BP medication. Refused all other meds this shift. MD notified of refusal/family aware of same. 9/12/19 11:09 a.m. Resident refused her 9:00 a.m. medications offered on several occasions. Primary Care Physician (PCP) made aware. 9/13/19 11:56 a.m. Resident was offered on several occasions her 9:00 a.m. medications. Refuses stated, I already took my medications. PCP made aware. 9/15/19 3:17 p.m. Patient was found approximately 12:13 p.m. wondering outside from the premises found by Certified Nurse's Assistant (CNA) and assisted back into the facility and assessment made and there was no found injuries or active distress and vital signs are stable. Resident stated, I was looking for my daughter. I was on the sidewalk. Resident also had her cell phone in her hand. NHA, MD and family member was notified. Initiated close monitoring of 1:1, wander guard, and updated information inserted into elopement books. Patient was last seen by assigned CNA at 11:45 a.m. 9/15/19 5:17 p.m. Physician called back informed him condition no new orders noted and will continue to monitor patient with aide at the bedside on 1:1 as well as 15-minute checks for safety of patient. 9/16/19 3:15 p.m. Attempted to call resident daughter two times today. Both calls had no answer or call back. However, the unit manager called from her cell and the resident's daughter answered stating that she is aware of what happened and that her Mom only left looking for her because she had not been here to see her mom and typically, she normally sees her every day and her mom missed her. She states she will be in to see her mom today. 9/16/19 3:42 p.m. Resident remains on one to one supervision with CN[NAME] CNA states that the resident ate her meals today and did not allow her to assist with her care. Writer spoke with the resident who stated when asked that she was just going for a walk and writer encouraged her to ask someone to go with her next time. As the writer was leaving the resident's room she stated, They are lying on me I didn't go anywhere. Resident was seen by medical Advanced Registered Nurse Practitioner (ARNP) with orders for labs. Writer called and spoke with resident's daughter who stated that resident said she was coming to see her as she had been sick and was not in for 3 days when she is usually here every night. Daughter states that she will be in to see resident tonight. 9/18/19 7:44 a.m. Care plan/Interdisciplinary Team (IDT) note: The IDT met 9/17/19 about resident and decided that if the resident had a good night (displaying no maladaptive behaviors and signs of exit seeking) the 1:1 will be discontinued in the morning. Psych ARNP agreed. This writer confirms resident has not displayed any behaviors in the last 48 hours of exit seeking and therefore 1:1 has been removed. MD and daughter aware. 9/18/19 1:26 p.m. Resident placed on safety checks Q15 minutes until re-evaluated by the IDT. Q15 minute sheet to be completed each shift as well as task section of CNA plan of care shall be documented. MD and family aware. 9/19/19 5:46 p.m. Results of Culture and Sensitivity (C&S) called to MD with order for [MEDICATION NAME] 250mg QD x 3 days and acidophilus BID for 2 weeks. 9/20/19 2:57 p.m. SSD spoke with the resident's daug

Based on interviews with the Nursing Home Administrator, Director of Nursing, nursing staff, certified nursing assistant staff, the resident, the resident's family, the attending Physician staff and review of the facility policies and the resident's medical record, the facility failed to ensure that one (Resident #5), of four residents requiring supervision was provided with the needed supervision to prevent the resident from leaving the facility without the staff's knowledge. The resident was [AGE] years old and looked forward to her daughter's daily visits. When her daughter did not visit her for three days, the resident left the facility unescorted and without the staff's knowledge to go look for her daughter. The resident was diagnosed with [REDACTED]. The resident had a history of [REDACTED]. She was refusing to take physician ordered medications that included [MEDICAL CONDITION] medication for depression and Paranoid [MEDICAL CONDITION] and an anticoagulant (blood thinner) for [MEDICAL CONDITION] Fibrillation (defined by the American Heart Association as a quivering or irregular heartbeat, 'arrhythmia' that can lead to blood clots, stroke, heart failure, and other-related complications). She recently had a syncopal episode (loss of consciousness) but refused to go to the hospital. On 7/13/2018, the resident's physician determined that the resident did not have the capacity to make health care decisions for herself or provide informed consent for medical treatment. On 9/15/19 between 11:45 a.m. and 12:15 p.m. the resident left the facility without the staff's knowledge, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, passed a wooded lot and out of sight of the facility. The resident was found standing in the grass between the street and the sidewalk by a staff member that was driving back from lunch. The Nursing Home Administrator (NHA) and the Director of Nurses (DON) were notified of the elopement but did not come into the facility until the following day to investigate or ensure that all residents in the facility were safe. After the resident was found, the facility staff did not do a Head count, to ensure that all the other residents were in the facility and accounted for, until the 3:00 p.m. - 11:00 p.m. shift. Staff education was not started until the 3:00 p.m. - 11:00 p.m. shift and an investigation as to how the resident was able to walk out of the facility without staff knowledge was not started until Monday morning on 9/16/2019. The resident told staff that she went out the front door. The receptionist denied seeing the resident leave the facility and did not hear any alarms during the time determined by the facility of the resident's elopement. The facility did not have the doors checked by maintenance or the door company until Monday 9/16/2019. At the time of the elopement, the facility did not know if the resident was able to leave the facility without staff's knowledge due to a faulty door lock and/or alarm and did not station anyone at the front door or the other seven exits doors to ensure that no other resident was able to leave the facility unnoticed. The front door was inspected by the door company to ensure that the locks and alarms were operational on Monday morning, 9/16/2019. The remaining seven doors were not inspected by the door company to ensure that the alarms and locks were functioning properly until 10/3/2019. Though the resident had Dementia, impaired cognition, abnormalities of gait and mobility, the Nursing Home Administrator and the Director of Nurses said the resident was not at risk for harm or injury and the incident was not reported to any oversight agencies as an elopement. During interviews with the resident's Primary Care Physician, Medical Advanced Registered Nurse Practitioner (ARNP), Psychiatric Advanced Practiced Registered Nurse (APRN), and the resident's daughter, said the resident was not safe to go off the facility grounds unescorted. The facility failed to ensure the safety of Resident #5 on 9/15/19 when she was able to exit the facility without the staff's knowledge. The facility failed to ensure the safety of all the residents in the facility by not immediately ensuring that all residents were in the facility and accounted for. The facility did not begin an investigation of the event until the following morning and did not ensure that all exit doors were monitored until the alarms and locks were inspected by the maintenance department or the door company. This resulted in findings of Immediate Jeopardy that began on 9/15/2019 and was removed on 10/3/2019. Findings included: On 10/1/19 at 2:00 p.m. an interview was conducted with the Director of Nurses (DON), Risk Manager Specialist (RMS), and the Unit Manager (UM) regarding elopements. The DON said there was one resident, Resident #5, that went out of the facility, but it was not an elopement. She said the resident took her cell phone outside the building to call her daughter because she was worried that her daughter had not been to see her for a while. The RMS said the resident went out to the side walk in front of the facility and turned right. The resident was found down the street in front of an Assisted Living Facility. The RMS said Staff in the facility did not see her leave the facility. A staff member driving back from lunch saw the resident and brought her back to the facility. She said, the resident was assessed and found to be free of injury. When asked why the facility did not treat this incident as an elopement, the RMS said that the resident did not have history of elopement, she had a Leave of Absence (LOA) order from the physician, and the resident said she was safe because she walked down the middle of the sidewalk and had her cell phone with her. The RMS said the resident was assessed by therapy and was found to be safe because she knew when and how to cross the street. Again, the DON and the RMS verified that the facility did not consider the event to be an elopement. On 10/1/19 at 2:15 p.m., an interview was conducted with the Nursing Home Administrator (NHA) regarding the elopement. He said the event was not considered to be an elopement because the resident said she was safe, and she had her cell phone with her. He said the resident had a physician's orders [REDACTED]. (Review of the LOA order read as follows: (MONTH) go LOA with Escort with meds. Ordered 9/4/19). The NHA was asked if he was comfortable with the fact that the resident left the facility without the staff knowing about it, walked out to the public sidewalk, proceeded down the street in the direction of her daughter's house, and was found down the street by a staff member coming back from lunch. He said he was uncomfortable that she left the building without signing out, but because the resident said she was safe and had her cell phone with her he was not uncomfortable about her leaving the facility. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the nurse's notes read as follows: 9/4/19 7:41 p.m. eINTERACT SBAR (Situation Background Assessment Recommendation): Change in condition: Loss of Consciousness ([MEDICAL CONDITION]). 9/4/19 9:52 p.m. Resident had a syncopal episode, she was aroused via sternal rub. Blood Pressure (BP) / Heart Rate (HR) was checked (142/87, 60) Emergency Medical Services (EMS) notified and upon assessment done by paramedics, resident was in [MEDICAL CONDITION] Fibrillation and daughter/resident refused to be transferred to the hospital for further evaluation. On call MD notified and await further orders. 9/5/19 11:48 a.m. Spoke with Dr. regarding resident's episode of [MEDICAL CONDITION] last night and that resident's daughter did not wish for her to go to the hospital. Meds reviewed with the doctor and vital signs of BP 123/58, Pulse 56, Respirations 20, Temperature 97.8 and Oxygen saturation 98% on room air. Order received for Electrocardiogram (EKG). 9/5/2019 11:42 p.m. The EKG was done with abnormal results received. Resident resting peacefully in bed, son at bedside visiting, resident denies pain or discomfort. No visible signs/symptoms or shortness of breath. Called placed to on - call Advanced Registered Nurse Practitioner (ARNP), she informed writer to call the ordering MD in AM with result, due to resident's history of [MEDICAL CONDITION]. Scheduled medications taken this shift by resident with much encouragement of son. 9/6/19 4:15 p.m. Continues to refuse medications, Medical Doctor (MD) aware and Power of Attorney (POA) notified. 9/7/19 4:10 p.m. Refused to take her morning medications. On call doctor informed. No new orders. 9/10/19 2:16 p.m. Resident alert with confusion, able to make needs known, denies pain this shift, no visible s/s of discomfort/distress. Offered meds, post blood pressure (BP), resident states, I will only take BP medication. Refused all other meds this shift. MD notified of refusal/family aware of same. 9/12/19 11:09 a.m. Resident refused her 9:00 a.m. medications offered on several occasions. Primary Care Physician (PCP) made aware. 9/13/19 11:56 a.m. Resident was offered on several occasions her 9:00 a.m. medications. Refuses stated, I already took my medications. PCP made aware. 9/15/19 3:17 p.m. Patient was found approximately 12:13 p.m. wondering outside from the premises found by Certified Nurse's Assistant (CNA) and assisted back into the facility and assessment made and there was no found injuries or active distress and vital signs are stable. Resident stated, I was looking for my daughter. I was on the sidewalk. Resident also had her cell phone in her hand. NHA, MD and family member was notified. Initiated close monitoring of 1:1, wander guard, and updated information inserted into elopement books. Patient was last seen by assigned CNA at 11:45 a.m. 9/15/19 5:17 p.m. Physician called back informed him condition no new orders noted and will continue to monitor patient with aide at the bedside on 1:1 as well as 15-minute checks for safety of patient. 9/16/19 3:15 p.m. Attempted to call resident daughter two times today. Both calls had no answer or call back. However, the unit manager called from her cell and the resident's daughter answered stating that she is aware of what happened and that her Mom only left looking for her because she had not been here to see her mom and typically, she normally sees her every day and her mom missed her. She states she will be in to see her mom today. 9/16/19 3:42 p.m. Resident remains on one to one supervision with CN[NAME] CNA states that the resident ate her meals today and did not allow her to assist with her care. Writer spoke with the resident who stated when asked that she was just going for a walk and writer encouraged her to ask someone to go with her next time. As the writer was leaving the resident's room she stated, They are lying on me I didn't go anywhere. Resident was seen by medical Advanced Registered Nurse Practitioner (ARNP) with orders for labs. Writer called and spoke with resident's daughter who stated that resident said she was coming to see her as she had been sick and was not in for 3 days when she is usually here every night. Daughter states that she will be in to see resident tonight. 9/18/19 7:44 a.m. Care plan/Interdisciplinary Team (IDT) note: The IDT met 9/17/19 about resident and decided that if the resident had a good night (displaying no maladaptive behaviors and signs of exit seeking) the 1:1 will be discontinued in the morning. Psych ARNP agreed. This writer confirms resident has not displayed any behaviors in the last 48 hours of exit seeking and therefore 1:1 has been removed. MD and daughter aware. 9/18/19 1:26 p.m. Resident placed on safety checks Q15 minutes until re-evaluated by the IDT. Q15 minute sheet to be completed each shift as well as task section of CNA plan of care shall be documented. MD and family aware. 9/19/19 5:46 p.m. Results of Culture and Sensitivity (C&S) called to MD with order for [MEDICATION NAME] 250mg QD x 3 days and acidophilus BID for 2 weeks. 9/20/19 2:57 p.m. SSD spoke with the resident's daughter/Health Care Proxy (HCP). Social Service Director (SSD) suggested room [ROOM NUMBER]. Resident daughter declined to allow the room change. She stated the resident's family would be in each day and she felt that was enough to satisfy the resident. Review of the admission Minimum Date Set (MDS) with an Assessment Reference Date (ARD) of 7/11/19, revealed the following information. Hearing, Speech, and Vision. Section B Subset B1200: Corrective lenses (contacts, glasses, or magnifying glass) used in completing B1000, Vision. The code entered was 1 which indicated the resident used corrective lenses in order to complete the vision potion of Section B. Cognitive Patterns Section C Subset: C0200-Brief Interview for Mental Status (BIMS)- The summary score was 9 out of 15 which indicated that the resident's cognition was moderately impaired. Functional Status Section G Subset G0110 Activities of Daily Living (ADL) Assistance [NAME] Bed mobility Code 2-limited assistance, Code 2-one person assist B. Transfer Code 1 -supervision, Code 1-set up only C. Walk in room Code 1- supervision, Code 1- set up only D. Walk in corridor Code 1- supervision, Code 1- set up only E. Locomotion on unit Code 1- supervision, Code 1-set up only F. Locomotion off unit Code 1- supervision, Code 1-set up only G. Dressing Code 2-limited assistance, Code 2-one - person physical assist H. Eating Code 1- supervision, Code 1- set up only I. Toilet use Code 2-limited assistance, Code 2-one - person physical assist [NAME] Personal Hygiene Code 2-limited assistance Code 2-one - person physical assist Subset G0120 Bathing [NAME] Self-performance: Code 3-Physical help in part of bathing activity B. Support provided: Code 2-one- person physical assist Subset 0300 Balance During Transitions and Walking Moving from seated to standing position: Code 1-Not steady, but able to stabilize without staff assistance. Walking (with Assistive Device (AD) if used): Code 1-Not steady, but able to stabilize without staff assistance. Turning around and facing in the opposite direction: Code 1-Not steady, but able to stabilize without staff assistance. Moving on and off toilet: Code 1-Not steady, but able to stabilize without staff assistance. Surface to surface transfer (Transfer between bed and chair or wheelchair): Code 1 Not steady, but able to stabilize without staff assistance. A review of the latest care plan revealed the following pertinent focus areas: Cognition: The resident has Dementia or impaired thought processes related to short term memory loss, resident is a loner and does not like to complain. Requires encouragement to interact and Socialize. Date initiated: 7/17/19. Revision date: 7/19/19. Discharge Planning: The resident wishes /or responsible party wishes to: Long Term Care, has dementia and cannot care for self. Date initiated: 4/11/19. Revision on 9/16/19. Behavioral: The resident is noted with the following behaviors: Hears things, believes others are talking about her, paranoia, self isolation. Date initiated 1/10/19. Revision on 9/16/19. Behavioral: The resident has a behavior problem r/t long standing history of refusing medications and care related to issues. She was readmitted recently and continues to refuse medications and now food at times. She has [DIAGNOSES REDACTED]. Date initiated 8/6/19. Revision on 9/16/2019. Vision: The resident has impaired visual function related to history of [MEDICAL CONDITION]. Had bilateral cataract surgery March/May (YEAR). Hypertensive Retinopathy is at risk for vision decline. Wears eye glasses as needed, at resident discretion. Eye exam 9/2018 identifies Hypertensive Retinopathy, astigmatism right eye, presence of interocular lenses. Date initiated: 7/18/18 Revision on: 9/18/19 Anticoagulation: On anticoagulation therapy medication related to [MEDICAL CONDITION] Fibrillation, cardiac arrhythmia. Date initiated 7/17/18. Revision on: 7/19/19. Intervention: Provide safe environment: Assist with transfers/mobility as needed, protect extremities from trauma to lessen the possibility of bleeding/injury. [MEDICAL CONDITION] Medication: The resident uses [MEDICAL CONDITION] medications related to antipsychotic to manage: unspecified dementia with behavioral disturbance. Antidepressant use for the treatment of [REDACTED]. Revision on: 7/25/19. After the resident eloped from the facility on 9/15/19, a care plan was initiated for elopement risk: Resident is at risk for elopement. The resident has cognitive impairment and is independently mobile. Date initiated: 9/15/19. Revision on: 9/18/19. On 10/2/19 9:45 a.m., 12:15 p.m., and 1:45 p.m. attempts to interview the resident were unsuccessful. Each time, she was observed in her bed with the bed covers pulled over her head. She answered to her name but did not come out from underneath the covers. She did not respond to any questions. At 4:20 p.m., the resident was observed lying on her right side with her head under the bed covers. She answered to her name and uncovered her head. She responded to general questions regarding going outside of the facility. She said she goes out of the facility with her family and goes out of the facility to the store by herself. She said the store was close by, so she was able to walk to it by herself. She said she walks on the sidewalk and goes to the store whenever she needs something. She did not answer any more questions and pulled the bed covers back over her head. A review of the documentation on the resident's Medication Administration Record [REDACTED]. The medications and refusals were as follows: Cartia XT Capsule Extended Release 24-hour 180mg. Give one capsule by mouth one time a day for Cardiac (antihypertensive). She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/11, 9/12, 9/13, and 9/14/2019. [MEDICATION NAME] Oxalate tablet 5 mg. Give 1 tablet by mouth one time a day for Depression. She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/10, 9/11, 9/12, 9/13, and 9/14/2019. [MEDICATION NAME]-[MEDICATION NAME] tablet 10-12.5 mg. Give 1 tablet by mouth one time a day for hypertension. She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/10, 9/11, 9/12, and 9/13/19. Memantine HCL ER Capsule Extended Release 24-hour 28 mg. Give one capsule by mouth one time a day for dementia. She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/8, 9/10, 9/11, 9/12, 9/13, and 9/14/2019. Potassium tablet. Give 20 mEq by mouth one time a day for Low Potassium. She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/10, 9/11, 9/12, 9/13, and 9/14/2019. Apixaban tablet 5mg. Give 1 tablet by mouth two times a day for [MEDICATION NAME] for [MEDICAL CONDITION] Fibrillation (Anticoagulant). She refused the medication on 9/3, 9/4, 9/5, 9/6, 9/7, 9/10, 9/11, 9/12, 9/13, and 9/14/2019. [MEDICATION NAME] tablet 15 mg. Give7.5 mg by mouth at bedtime for depression. She refused the medication on 9/3/2019. [MEDICATION NAME] tablet 0.5 mg ([MEDICATION NAME]). Give 1 tablet by mouth at bedtime for Paranoid [MEDICAL CONDITION]. She refused the medication on 9/3/19. On 10/1/19 at 3:50 p.m. and interview was conducted with the DON and NH[NAME] The DON and the NHA confirmed the policy named Elopement Management that was undated was their only elopement policy. The NHA stated they also follow The Tree to make decisions on whether or not an elopement has occurred. The DON and the NHA were asked according to The Tree did a resident/patient leave the premises or a safe area without authorization and/or necessary supervision? The DON and the NHA stated Yes. The DON and the NHA were asked was the resident at risk for harm or injury? The DON and the NHA stated No. The DON was asked if the resident was a fall risk. The DON stated, No. The DON was asked to pull up the resident's care plan and the DON said before pulling up the care plan that the resident was at risk for falls only because she was on [MEDICAL CONDITION] medications and because of their side effects. The DON said everyone on [MEDICAL CONDITION] was at risk for falls. The DON was asked since the resident was taking [MEDICAL CONDITION] medications, which puts her at risk for falls, is she a fall risk? The DON fumbled over her words and said well we are in the process for redoing all the residents' care plans because they are not accurate. We started that on 9/27/19 with a target date of completion by two weeks. The DON then read the resident's fall risk care plan out loud. She said, the resident was at risk for falls or fall related injury because of gait/balance problems, psychoactive drug use, and she had a slow steady gait. She required 1 person assist and cues for assistive device/walker. The DON said, That's not right because she does not use a walker anymore. She could out walk me. The NHA said she hasn't had a fall since I've been here. The DON nodded her head and said me either. The NHA said we asked therapy to do a safety screening on her and speech evaluated her. The NHA was asked why speech evaluated her related to this incident. He said well I'm not exactly sure what they do we just asked for a safety evaluation. The NHA continued to say the resident was always walking but typically she walked towards the dining room not the front desk area. He stated, I've never seen her go past my office. She was also far away from the road when we did the measurements. The NHA was asked who did the measurements and he said, I can't remember exactly but we took a measurement from where she was standing when she was found. The DON said sometimes you'll ask her if you can sit next to her on her bed, but she won't let you because she's paranoid at times she has [MEDICAL CONDITION]. The NHA stated, Because of this incident we educated all of our staff except a couple of PRN staff that don't come here anymore or are on leave of absence. We even threw in some code silver drills just because. The DON said prior to the resident leaving the facility alone she was assessed on the admission assessment and determined not to be an elopement risk. She said the resident was assessed after she left the facility unattended and determined to be an elopement risk. The DON was asked to show her elopement risk assessment and the DON looked at the administrator and said, Is that the BIMS score? The NHA did not answer her question. The DON then said well there's not an actual elopement risk assessment we just care planned her and put a wander-guard on her. We just met with the Interdisciplinary Team (IDT) and decided she was an elopement risk. The NHA and the DON were asked, So given her risk for falls, her history of paranoid [MEDICAL CONDITION], dementia, leaving the building, walking down the street and or any other risk factors, did you feel the resident was at risk for injury or harm? The NHA and the DON both stated No. Both the DON and NHA said the incident was not reported to any oversight agencies. After the interview, the falls care plan was reviewed and revealed that during the interview with the DON and NHA, the DON failed to read the care plan in its entirety. She omitted that the resident was at risk for falls or fall related injury related to a previous fall. The fall care plan read as follows: At risk for falls or fall related to injury because of previous fall, gait/balance problems, psychoactive drug use. She has a slow steady gait. Date initiated 1/11/19. Revision on: 9/16/19. A review of the Physician's Evaluation of Resident's Capacity to make Health Care Decisions or Provide Informed Consent indicated that on 7/13/18, the resident's physician determined that the resident was unable to make health care decisions for herself or provide informed consent for medical treatment. The determination was based on the physician's examination that included, Review of all medical records in the patient chart, including hospital records, laboratory reports, x-rays and consultant's reports to confirm capacity to make health care decisions or provide informed consent. According to the Climatological Report (Daily) dated (MONTH) 16th, 2019 by the National Weather Service revealed on (MONTH) 15th, 2019 in the St. Petersburg, Florida area the temperature high for the day was 88 degrees Fahrenheit and the temperature low overnight from 8:00 p.m. to 8:00 a.m. was 79 degrees Fahrenheit. In the Tampa area the relative humidity averaged 74% on (MONTH) 15th, 2019. Review of the heat index from the National Weather Service revealed with a high of 88 degrees Fahrenheit and an average relative humidity of 74% the temperature outside felt as if it was 100 degrees. The National Weather Service indicated extreme caution with the likelihood of heat disorders with prolonged exposure or strenuous activity. On 10/2/19 at 12:04 p.m., a telephone interview was conducted with the resident's Primary Care Physician (PCP). He verified that he took care of Resident #5 and the majority of the residents at the facility. He stated that he truly did not recall the resident leaving the facility and walking down the sidewalk alone. He said his nurse practitioner might know and agreed with his order for may go LOA with escort. On 10/3/19 at 9:49 a.m., a telephone interview was conducted with the PCP's Advanced Practice Registered Nurse (APRN). The APRN stated she followed Resident #5 and said she was very familiar with her. The APRN stated, I'm not sure if they told me about her leaving the facility alone but they might have told me about it. I don't have my notes on me. She said, We have been working very closely with her. She said, psych is following her but she's not responding to anyone. She's not caring for herself like she used to and she's not eating like she used too. We even sent her out to the hospital at one point, but they said nothing was wrong with her. Psych recommended medications but she refuses her medications and those medications take a good three weeks to kick in. She has not responded to anyone to let us know what's wrong. They usually call me for every little incident I couldn't image they wouldn't have told me. The APRN was asked if the resident was safe to leave the building without an escort and she said, No, no, no she would not be safe no. When I'm at the facility she will respond to my commands but I'm not there every day so as soon as I leave, she won't listen to anyone. On 10/3/19 at 10:13 a.m. an interview was conducted with the psychiatric services APRN. She stated she was familiar with the resident and stated she recalled when she left the facility without an escort. She was asked if the resident was safe to do so and she stated, No she's not safe to leave by herself. She's demented and has a lot of paranoia, yeah, I don't even know how she got out but no she's not safe to go out alone. She said, because of her paranoia and her dementia she does not want to take her medication. Staff is really good about positive reinforcement to take her meds. The resident she kept thinking staff was putting stuff in her food and giving her medications. Now her daughter has been coming in, in the afternoons to help her take her medications. That's been going on for about a month or so. At 10:23 a.m., the APRN called back and said she remembered the resident saying something about how she, doesn't know why she walked outside. On 10/4/19 10:02 a.m., a telephone interview was conducted with the on-call physician on 9/15/19. He stated he had never been to the facility and was not familiar with the resident. He stated I was given a call when I was on that day from a nurse from the facility. It was reported that the patient went out of the facility. She was outside and she decided to come back in willingly. He said when she came back in, she was in good state of mind because I asked if they assessed her. They said she was not confused or disoriented, and she had no physical injuries. I told them they should keep a close eye on her, so she doesn't go back outside alone again. He said, No she was not safe to go outside by herself because we didn't know she wanted to go outside. I told them to keep a close eye on her after she went outside because I did not want her going back outside alone. And the fact that they called me means she was not authorized to go outside alone in the first place. He said, the resident Was mentally and physically okay so there was no further intervention that was needed from me at that point. On 10/3/19 at 1:44 p.m. an interview was conducted with the resident's daughter. She said she was initially led to believe that the resident was wandering around inside the facility looking for her. She said she had been sick and missed a couple days of visiting her mother. She said she came to visit the next day. She said her mother did not show any signs of distress and seems her normal self. She said the NHA told her that the resident was found outside of the facility on the sidewalk. She said she was shocked but didn't make a big deal about it. When asked if she felt that her mother was safe to be outside of the facility by herself, she said, No due to her memory issues. She said the resident needs glasses to see and does not always wear the glasses and may not be able to see where she is going. She said the resident is weak and may collapse if she walks too far. A review of the Interview Follow-up Questions (Undated) related to the written statement provided by Staff C revealed that one of the questions was, Was she wearing her glasses. The answer was No. The document was signed (Undated) by Staff C. On 10/3/19 at 11:44 a.m. a telephone interview was conducted with Staff B Certified Nurse's Assistant (CNA) who found the resident outside and away from the facility. She said she was coming back from lunch, going south on 31st street towards the facility, when she saw what she thought may be a resident walking away from the facility down the street on the sidewalk. She said, at that time of day the traffic was heavy on the street. She pulled into the facility parking lot and flagged down a co-worker that was also coming back from lunch. She said she told her co-worker what she saw and got into the co-worker's vehicle to go get the resident. She said when they got to the resident, she was standing at the second entrance to an Assisted Living Facility. She was standing in the grass, not on the sidewalk, between the street and the sidewalk. She said the resident had a worried look on her face as if she was deciding what to do next. Staff B said, as her co-worker turned into the driveway, she got out of the vehicle before it stopped and called the resident's name. She said she knew the resident because she had worked with her before but said the resident was not currently on her assignment. She called the facility to inform them that the resident was found down the street and that they were returning to the facility. She said the resident responded to her name and when the CNA asked her where she was going, she said she was going to find her daughter and wanted the CNA to go with her. The CNA explained that they had to go back to the facility. The resident allowed her to turn her around and hold her hand. She said the resident held her hand all the way back to the facility. She said the resident told her that she had gone out the front door of the facility to go find her daughter. On 10/2/19 11:28 a.m., an interview was conducted with Staff C (CNA) who assisted with finding the resident away from the facility. She said

Based on record review of the clinical record, nurse's and physician's notes, laboratory reports, and the facility's policies and procedures and interviews with the risk manager, nursing and administrative staff, laboratory representative, and the resident's primary care physician, the facility failed to ensure one (Resident #2) out of six sampled residents was free from medical neglect. The facility failed to provide care and services necessary to ensure that physician ordered STAT (immediate) critical labs were reported to the physician in a timely manner. The potential for serious injury occurred due to delayed reporting of a critical lab result to the physician for Resident #2. The resident was totally dependent on staff for all toileting, bathing, personal hygiene, turning and repositioning in bed, and nutritional intake due to dementia and [DIAGNOSES REDACTED]. She was receiving all nutritional support and medications through a feeding tube. She was non-verbal, unable to make her needs known or be involved in decisions regarding her care. The resident had the right and deserved to be free of medical neglect while receiving nursing care, medications, nutrition, and medical care as prescribed by the physician while at the facility. The lack of structure to provide necessary care and services was evidenced by the delay in reporting due to the lack of communication between nursing staff, failure to check the fax machine for lab results and failure of the facility to answer the phone to receive critical lab results. The facility did not report the resident's critically high blood glucose level of 873 milligrams (ml)/deciliters (dl), normal serum glucose level was ,[DATE] ml/dl, to the physician until after her death. The facility's failure to protect Resident #2's basic rights to be free from medical neglect by not providing the physician with critical information so that he could make an informed decision on the course of the resident's treatment resulted in findings of Immediate Jeopardy, occurring on [DATE], which was removed on [DATE] and reduced to a scope and severity of a D. Cross reference to F684 Findings included: A review of the facility's policy titled, Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. On [DATE] a review of the medical record including the physician's progress notes, nursing notes and social services notes revealed that Resident #2, was a [AGE] year old long term care resident with [DIAGNOSES REDACTED]. The resident had a spouse, who was active in her care, and one son. She needed maximum care by the staff for all toileting, bathing, personal hygiene, turning and repositioning in bed, and nutritional intake. She was non-verbal and unable to make her needs known. She was receiving all nutritional support and medications through a feeding tube. The Advanced Registered Practical Nurse (ARNP) saw the resident on a monthly basis. She was seen on [DATE], ,[DATE], ,[DATE], and [DATE]. On the [DATE], the physician's progress read as follows, Reason for Appointment- Follow up. History of Present Illness- Past medical history significant for [MEDICAL CONDITION] disorders, [MEDICAL CONDITION], history of [MEDICAL CONDITION] [MEDICAL CONDITION] disorder, [MEDICAL CONDITION] Reflux Disease (GERD), Cardiac Artery disease (CAD). Patient nonverbal, seen in room, dependent for all Activities of Daily Living (ADL). Patient with contractures, and repositioned every 2 hours. No new skin breakdown reported. Medications and plan of care discussed with staff. Per staff no additional concerns on today's visit. Examination: General appearance: well developed and well nourished, in no acute distress. Eyes: sclera white. Neck/[MEDICAL CONDITION]: supple, thyromegaly (enlarged [MEDICAL CONDITION]), no Jugular Venous Distention (JVD). Cardiovascular: regular rate, no murmurs. Peripheral vascular: no leg [MEDICAL CONDITION], no cyanosis. Respiratory: clear to auscultation (listening with a stehoscope) bilaterally. Gastrointestinal: flat, no discoloration, Percutaneous Endoscopic Gastrostomy (PEG) tube in place- clean, dry and intact, (endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) normal bowel sounds, soft, no tenderness, no organomegaly (enlarged organs). Neurologic exam: Mental status: aphasic. Motor: [MEDICAL CONDITION]. Left facial droop, no acute focal signs. Follow up 4 weeks. Review of recent labs indicated that a Basic Metabolic Panel (BMP) done on [DATE] and the Glucose level of 166 mg/dl, normal was 70mg/dl -105mg/dl. There was no indication that the physician was notified of the result. On [DATE], [MEDICATION NAME] level was done and reported as 3.5 micrograms (u/g) per milliliter ml). The ARNP was notified and gave no new orders. A review of the resident Medication and Treatment Administration Records dated ,[DATE]-[DATE] indicated that the resident was receiving medications and treatment as prescribed the physician. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of [DATE], reflected: a. Under Section B. Hearing, Speech, and Vision, the assessment indicated that the moderate difficulty with hearing, inability to speak, unable to express ideas and wants, unable to understand verbal content, and moderately impaired vision. b. Under Section C. Cognitive Patterns, the resident was unable to complete the Brief Interview for Mental Status (BIMS). She had long and short term memory problems and was unable to make decisions regarding tasks of daily life. c. Under Section G. Functional Status, the resident was totally dependent on two people for bed mobility, transfers, and toilet use. She was totally dependent on one person for locomotion on and off the unit, dressing, eating, personal hygiene, and bathing. A review of the nurse's notes dated ,[DATE]- [DATE] did not give reference to any changes in the resident's condition. The nurse's notes read as follows, [DATE], resting much of the shift, is non -verbal, unable to make her needs known and total care is provided. Has oxygen via nasal cannual. Enteral feeding via Gastrostomy (GT). GT placement verified, patent, flushes easily, and has no residual. Skin warm and dry. Incontinent of bowel and bladder. [MEDICAL CONDITION] precautions in place, no s/s of [MEDICAL CONDITION] activity this shift. Turned and repositioned as regular intervals. [DATE]: Social Services note: Alert but cognitively impaired. She rarely is able to make her needs known. She requires maximum care to complete her ADLs. When out of bed, she is propelled by another in a recliner. She is a passive participant whenever at an activity. Her code status is Do Not Resuscitate Order (DNRO) and is on the chart. She has an incapacity document and a Health care Proxy (HCP). Her long range plan is Long Term Care (LTC). [DATE], resident seen for wound rounds area to left thigh and left upper and lower buttocks are resolved. [DATE], A call was placed to (the resident's husband) regarding care conference scheduled for [DATE] at 1:30 p.m. He is unable to attend due to work. Per his request, we will accommodate him for a meeting on [DATE] at 1:30 p.m. [DATE], ARNP called and informed of [MEDICATION NAME] level, no new orders given. The next note was on [DATE] at 2:28 p.m. and indicated a change of condition. The note read as follows, The Certified Nursing Assistant (CNA) came to the nurse to assess the resident. The resident had a temperature of 101.5 degrees Fahrenheit. The physician's office was called. Awaiting return call. The note was signed (e-SIGNED) by the Registered Nurse/Unit/Manager (Staff B). An additional nurse progress note reflected: On [DATE] at 8:45 p.m., X-ray results were in and called into the on call Dr. Orders were given for [MEDICATION NAME]. Dx. Pneumonia. Signed (e-SIGNED) by Staff J (Licensed Practical Nurse, LPN). A review of the Medication Administration Record, [REDACTED]. A nurse's note written on [DATE] at 9:15 a.m. read as follows, alert, verbally unresponsive, [DEVICE] patent feeding given as ordered, no distress noted, resting with eyes closed at long intervals. At 8:45 a.m. RHC (respirations have ceased), no heart sounds or pulse palpable. The physician and husband were notified. Signed (e-SIGNED) by Registered Nurse (Staff H). An interview was conducted with the Unit Manager (Staff B) at 3:00 p.m. on [DATE]. She said, on [DATE] she received orders from the physician for a STAT (immediate) chest X-ray and STAT laboratory tests for a complete blood count (CBC) and a comprehensive metabolic panel (CMP). She said she submitted the requisitions to the mobile X-ray provider for the STAT chest x-ray and to the laboratory for the blood work. She said by the time she left at the end of her shift, at approximately 5:15 p.m., neither result for the chest x-ray nor the blood work had been sent to the facility. The Unit Manager (Staff B) said, when she returned the next day, on [DATE], between 8:45 a.m.-9:00 a.m., she saw the lab report on the fax machine. She said she also saw a sheet of paper on the fax machine from the laboratory (Lab) that read something like, Attention: critical please call. She reviewed the laboratory results and noted that the critically high glucose, serum level was 873 ml/dl, the normal range for a serum glucose level was ,[DATE] mg/dl. She said at that time the night shift RN, (Staff H) was still working and the day shift LPN, (Staff I) was at the nurse's station. She showed both of them the faxed laboratory report and asked them if either one had seen the abnormal laboratory results. She confirmed that both nurses denied having seen the lab reports. Staff B said, it was at that time that she reported the results to the Director of Nursing (DON). She said she then called the 3:00 p.m. - 11:00 p.m. LPN (Staff J) and asked her if she had seen the laboratory results on her shift. Staff J said at 8:45 p.m. on [DATE], she called the physician to report the abnormal chest X-ray results but she did not see any laboratory reports for this resident before she left at the end of her shift. Staff B said, after she spoke with the 3:00 p.m. - 11:00 p.m. LPN (Staff J), she called the laboratory to see if they called the facility to report the critical labs. She said that the laboratory representative said they had called the facility several times with no answer. On [DATE] at 2:30 p.m., an interview was conducted with the DON. She said, I was told that Resident #2 had a critical blood glucose level of 873 mg/dl that was done on [DATE] and left on the fax machine until [DATE]. The DON said she spoke with the 3:00 p.m.-11:00 p.m. direct care nurse (Staff J) for Resident #2 on [DATE], no time given. The nurse told the DON that the resident had no increased temperature or respiratory distress on her shift. The nurse said she did an assessment. There was no documentation in the resident record of such assessment that could be found. The DON verified that the nurse did not document the assessment or condition of the resident for the entire 3:00 p.m. - 11:00 p.m. shift on [DATE]. The DON said the nurse was a new nurse. She said the nurse said she did not see the laboratory results on the fax machine during the 3:00 p.m.-11:00 p.m. shift. The DON said the 3:00 p.m. to 11:00 p.m. supervisor checked the fax machine as part of the supervisory tasks but, the supervisor was not on duty on [DATE]. She said the nurses were also responsible for checking the fax machine throughout their shifts, especially if there was a STAT laboratory report pending. The DON said, during shift report, the nurses were supposed to inform the on-coming nurse of pending test results, especially if the tests were ordered STAT. The DON said, after the incident was brought to her attention on [DATE], she called the laboratory (no time was given) to see why they did not call the facility on a critical laboratory result. She was told that the laboratory had called, but no one at the facility answered the phone. The DON said she did not follow up with the physician regarding the incident. She said it was the responsibility of the unit manager to call the physician. The DON said she spoke only with the 3:00 p.m. - 11:00 p.m. nurse regarding the process for ordering, obtaining, and reporting laboratory results but she did not complete an education form. She said there was no other in-services/education conducted with all the facility nurses regarding ordering, obtaining, and reporting laboratory result. She said there was no follow-up regarding the failure of the staff to answer the telephone or check the fax machine on a regular basis. She said there was no incident report filed, no investigation completed and no mandated reports to outside agencies filed. On [DATE] at 9:30 a.m., the Nursing Home Administrator (NHA) verified that there were no incident reports found or education provided related to ordering laboratory tests, obtaining results, or reporting results to the physician. She said after the incident, she checked the fax machine and the phone system to ensure that both were in working order. She said the fax machine continued to deliver other documents throughout the evening and night shifts. She said the problems were not related to a mechanical failure for either the phone or the fax machine. She said, There is a receptionist at the front desk until 7:00 p.m. After 7:00 p.m., the phone is switched over to ring at the nurses' stations. The phone and fax machine functioned properly on both shifts. On [DATE] at 11:30 a.m. the Registered Nurse Consultant (RNC) verified that the facility did not have a policy or a written procedure for ordering laboratory tests, obtaining the results, or notification of critical results to the physician until the in-services were started on [DATE]. On [DATE] at 3:30 p.m., an interview was conducted with the 3:00 p.m. -11:00 p.m. Registered Nurse/Supervisor (Staff F). She said as part of her duties as the supervisor, she checked the fax machine throughout the shift and notified the nurses when laboratory results arrive. She said, in addition, all the nurses were also responsible for checking the fax on a regular basis, especially when they were waiting for STAT laboratory results. On [DATE] at 8:50 a.m., an interview was conducted with Resident #2's Primary Care Physician. He was also the facility's Medical Director. He verified that the facility did not notify him of the resident's blood glucose level until after the resident had expired. He said it was possible that the glucose level was high due to an infection. Based on the STAT chest X-ray results done on [DATE], the resident was diagnosed with [REDACTED]. On [DATE] at 10:30 a.m., an interview was conducted with a representative from the contracted laboratory that was used by the facility. She said, The lab faxed the critical lab results to the facility on [DATE] at 7:40 p.m. An Urgent Fax, with the resident's name and date that showed Urgent Please Call was sent at 7:45 p.m. At 7:46 p.m., the results were faxed again. At 9:15 p.m., the results were faxed manually. At 9:36 p.m., the results were refaxed by the system. She said, after the original fax was sent at 7:40 p.m., the lab called the facility and got no answer so at 7:45 p.m. the Urgent fax was sent. On [DATE] at 12:20 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. LPN (Staff I) who was assigned to Resident #2. He said he assisted with after care following her death on [DATE]. He said he was unaware of the abnormal laboratory results until it was brought to his attention. He could not remember who brought it to his attention. He said he received one on one education and possibly a group education related to reporting critical labs to the physician. He was very vague on who gave the education and when it was done. He said he had no education on checking the fax machine for lab results. He said he did not know if anyone was assigned to check the fax machine for labs, mechanical failures, or to make sure the machine had paper. He said if the machine ran out of paper the machine would beep the next time something was sent to the facility to alert the staff to replenish the paper. He said he frequently checked the fax machine throughout his shift and said if he saw a critical lab result on the fax, and it was not related to his resident, he would notify the nurse that was responsible for the resident with the critical labs. The nurse said he checked the fax machine frequently. In his earlier statement he said, he was Unaware of the abnormal laboratory results until it was brought to his attention, which was approximately two hours after the start of his shift at 7:00 a.m. On [DATE] at 3:13 p.m., a telephone interview was conducted with the 3:00 p.m. - 11:00 p.m. LPN (Staff J). She said she knew that someone was supposed to check the fax machine but it was not her. She said, She never checked the fax machine during her shifts. She said she was aware that the resident had STAT laboratory tests pending. She said she flushed the resident's feeding tube between 9:30 p.m. and 10:00 p.m. and the CNA changed the resident around that same time. She said the resident did not show signs or symptoms of distress. Her respirations were even and unlabored. She said the resident opened her eyes as she usually did when her name was called. She verified that she did not do vital signs, temperature and did not fully assess the resident after the increased temperature earlier in the day. She said that Resident #2 was her usual self throughout the shift. The nurse said she reported the abnormal chest X-ray results to the physician but did not see the laboratory results on her shift. On [DATE] at 6:00 p.m., an interview was conducted with the 11:00 p.m.-7:00 a.m. RN (Staff H). She said that in the shift report from the 3:00 p.m.-11:00 p.m. nurse she was told that the resident had a chest X-ray that showed pneumonitis and the physician ordered [MEDICATION NAME]. However, she said she was not told, in report, that the resident had STAT labs and the results were pending. She said if she had known, she would have checked the fax machine throughout the night. She said the resident was her usual self throughout the night. She said the resident had even respirations with no coughing or congestion. The nurse said the record review revealed no vital signs were taken after the elevated temperature was documented in the [DATE] nurses note. The last full set of vital signs, including temperature was documented on [DATE] as blood pressure ,[DATE], temperature 97.2, pulse 78, and respirations 20. The vital signs were within normal limits. There were no nurse's notes regarding the resident's condition on [DATE] during the 3:00 p.m. - 11:00 p.m. shift. A review of the vital signs history from ,[DATE]-[DATE] indicated that vital signs had not taken from [DATE] - [DATE]. On [DATE] at 10:00 a.m., an interview was conducted with the NHA. She said that the facility did not have a written policy specifically related to ordering laboratory tests, obtaining the results, and notifying the physician of the results. She said, beginning on the evening of [DATE], no specific time given, the facility started an in- service with all the nurses related to Lab test orders and management. On [DATE] beginning at 11:11 a.m., interviews with 13 staff members representing all three shifts, including nurses, Certified Nursing Assistants (CNA), social services, receptionist, and activities were conducted related to neglect. All those interviewed knew, in their own words, the definition of neglect, who to report to, and the number or where to locate the number for reporting neglect. On [DATE], the Register Nurse Consultant (RNC) indicated to the survey team that the NHA and the DON had been relieved of their duties at the facility. An interim NHA and an interim DON had been assigned to the facility. On [DATE] at 2:00 p.m., an interview regarding the facility's corrective action plan was conducted with the Registered Nurse Consultant (RNC), the Interim Director of Nursing and the present Interim Nursing Home Administrator. The RNC said that there was a knowledge deficit related to the laboratory log. The nurses were completing the beginning of the log but not completing the following, Results received, MD notified, and new orders received and documented in the progress note. She said it all rolled back to the clinical morning meetings ineffectiveness. If performed correctly missing lab results would be caught in clinical meeting. Some of the nurses were having problems with scheduling laboratory tests in the Electronic Medical Record computer system. They were not scheduling the lab at a specific time, so no one knew when it was due. The RNC stated that she spoke with the laboratory regarding a back-up system. The laboratory was to call and e-mail the Director of Nursing for all critical lab results, even if they report the results to the nurse at the facility. The facility will continue to audit the process to verify that all critical labs were obtained and reported to the physician in a timely manner. All labs will be reviewed in the morning meetings and then in stand-down meetings at the end of the shift. The lab monitoring sheet will be reviewed to ensure completeness to include, Resident name, and room number, test ordered, Phlebotomist date and initials, results, MD notification, results on chart, orders received, orders reviewed, and note in chart. Audits will be on going and reviewed in the Quality Assurance meetings until resolved. The corrective action plan did not included in-services related to Abuse, Neglect, Exploitation, or Misappropriation of Resident Property. As of [DATE] at 4:00 p.m., 30 of 33 nurses (91%) had received the training. She said one of the three that had not received the training was no longer employed at the facility, one was on suspension, and one was on an extended sick leave. She said the nurses would not be able to return to work until they completed the in-service. Beginning on [DATE]-[DATE], twenty nurses to include six registered nurses and fourteen licensed practical nurses were interviewed related to their knowledge of ordering laboratory tests, obtaining the results, and reporting critical results to the physician in a timely manner. All those interviewed said they were in-serviced and were able to state and understand the process. During the interviews, seven of fourteen licensed practical nurses said that before the in-services they were unsure of how to use the Laboratory Monitoring Sheet. They said, because of the in-service, they understand why and how to complete the log.

Based on medical record review and interview, the facility failed to ensure that treatment and care were provided in accordance with professional standards of practice for one (Resident #2) of six residents related to critical lab values not reported to the physician in a timely manner. Review of the medical record including the physician's progress notes, nursing notes and social services notes revealed Resident #2, was [AGE] years old and a long term care resident. The resident had a spouse, who was active in her care, and one son. Resident #2 was totally dependent upon staff for completion of all activities of daily living related to dementia and [DIAGNOSES REDACTED]. She was unable to make her needs known. She received all nourishment through a feeding tube. Resident #2 and her family depended on the staff to provide nursing care, medications, nutrition, and medical care as prescribed by the physician and guided by the professional standards of practice. On [DATE] at 2:28 p.m., the resident was reported to have a temperature of 101.5 degrees Fahrenheit. The physician was notified and gave orders for a STAT (immediate) chest X-ray, and laboratory tests for a complete blood count (CBC), and a comprehensive metabolic panel (CMP). While abnormal chest X-ray results were reported to the physician on [DATE], a critically high glucose, serum level at 873 milligrams (ml) per deciliter (dl) was not reported to the physician by facility staff, despite multiple attempts at communication by laboratory staff via telephone and fax attempts. Facility nursing staff failed to communicate between shifts, answer the phone and check the fax machine for laboratory results. The critical laboratory results were not seen until the following morning on [DATE] between 8:45 a.m. and 9:00 a.m. after Resident #2 expired. The facility did not have a system in place to ensure that the physician received critical test values in order to have accurate and timely information to prescribe life altering and or life-saving interventions. This resulted in findings of Immediate Jeopardy, occurring on [DATE], removed on [DATE], and reduced to a scope and severity of a D. Cross reference to F600 Findings included: On [DATE], a review of the medical record including the physician's progress notes, nursing notes and social services notes revealed that Resident #2, was a [AGE] year old long term care resident, originally admitted on [DATE] (Admission Record), with [DIAGNOSES REDACTED]. The resident had a spouse, who was active in her care, and one son. The spouse declined to be interviewed. Resident #2 needed maximum care by the staff for all toileting, bathing, personal hygiene, turning and repositioning in bed, and nutritional intake. She was non-verbal and unable to make her needs known. She was receiving all nutritional support through a feeding tube for 20 hours per day. Review of the Quarterly Minimum Data Set (MDS) Assessment with an Assessment Reference Date of [DATE], reflected: a. Under Section B. Hearing, Speech, and Vision, the assessment indicated that the moderate difficulty with hearing, inability to speak, unable to express ideas and wants, unable to understand verbal content, and moderately impaired vision. b. Under Section C. Cognitive Patterns, the resident was unable to complete the Brief Interview for Mental Status (BIMS). She had long and short term memory problems and was unable to make decisions regarding tasks of daily life. c. Under Section G. Functional Status, the resident was totally dependent on two people for bed mobility, transfers, and toilet use. She was totally dependent on one person for locomotion on and off the unit, dressing, eating, personal hygiene, and bathing. On [DATE], a review of the resident's clinical record revealed the following information. The Advanced Registered Practical Nurse (ARNP) saw the resident on a monthly basis. She was seen on [DATE], ,[DATE], ,[DATE], and [DATE]. On the [DATE], the physician's progress read as follows, Reason for Appointment- Follow up. History of Present Illness- Past medical history significant for [MEDICAL CONDITION] disorders, [MEDICAL CONDITION], history of [MEDICAL CONDITION] [MEDICAL CONDITION] disorder, Gastro [MEDICAL CONDITION] Reflux Disease (GERD), [MEDICAL CONDITION] (CAD). Patient nonverbal, seen in room, dependent for all ADLs. Patient with contractures, and repositioned every 2 hours. No new skin breakdown reported. Medications and plan of care discussed with staff. Per staff no additional concerns on today's visit. Examination: General appearance: well developed and well nourished, in no acute distress. Eyes: sclera white. Neck/[MEDICAL CONDITION]: supple, thyromegaly (enlarged [MEDICAL CONDITION]), no Jugular Venous Distention (JVD). Cardiovascular: regular rate, no murmurs. Peripheral vascular: no leg [MEDICAL CONDITION], no cyanosis. Respiratory: clear to auscultation (listening with a stehoscope) bilaterally. Gastrointestinal: flat, no discoloration, Percutaneous Endoscopic Gastrostomy (PEG) tube in place- clean, dry and intact,(endoscopic medical procedure in which a tube (PEG tube) is passed into a patient's stomach through the abdominal wall, most commonly to provide a means of feeding when oral intake is not adequate) normal bowel sounds, soft, no tenderness, no organomegaly (enlarged organs). Neurologic exam: Mental status: aphasic. Motor: [MEDICAL CONDITION]. Left facial droop, no acute focal signs. Follow up 4 weeks. A review of recent labs indicated that a Basic Metabolic Panel (BMP) was completed on [DATE] and the Glucose level of 166 mg/dl, normal was 70mg/dl -105mg/dl. There was no indication that the physician was notified of the result. On [DATE], a [MEDICATION NAME] level was completed and reported as 3.5 micrograms (u/g) per milliliter ml). The ARNP was notified and gave no new orders. A review of the resident Medication and Treatment Administration Records, dated [DATE]-[DATE], indicated that the resident was receiving medications and treatment as prescribed the physician. A review of the resident Medication and Treatment Administration Records, dated ,[DATE]-[DATE], indicated that the resident was receiving medications and treatments as prescribed by the physician. A review of the nurse's notes, dated ,[DATE]- [DATE], did not give reflect any changes in the resident's condition. The nurses' notes read as follows, [DATE], Resting much of the shift, is non -verbal, unable to make her needs known and total care is provided. Has Oxygen via Nasal Cannula. Enteral feeding via Gastrostomy Tube (GT) placement verified, patent, flushes easily, and has no residual. Skin warm and dry. Incontinent of bowel and bladder. [MEDICAL CONDITION] precautions in place, no signs/symptoms of [MEDICAL CONDITION] activity this shift. Turned and repositioned as regular intervals. [DATE]: Social Services note, Alert but cognitively impaired. She rarely is able to make her needs known. She requires maximum care to complete her ADLs. When out of bed, she is propelled by another in a recliner. She is a passive participant whenever at an activity. Her code status is Do Not Resuscitate Order (DNRO) and is on the chart. She has an incapacity document and a Health Care Proxy (HCP). Her long range plan is Long Term Care (LTC). [DATE], resident seen for wound rounds area to left thigh and left upper and lower buttocks are resolved. [DATE], A call was placed to (the resident's husband) regarding care conference scheduled for [DATE] at 1:30 p.m. He is unable to attend due to work. Per his request, we will accommodate him for a meeting on [DATE] at 1:30 p.m. [DATE], ARNP called and informed of [MEDICATION NAME] level, no new orders given. The next note was on [DATE] at 2:28 p.m. and indicated a change of condition. The note read as follows, The Certified Nursing Assistant (CNA) came to the nurse to assess the resident. The resident had a temperature of 101.5 degrees Fahrenheit. The physician's office was called. Awaiting return call. The note was signed (e-SIGNED) by the Registered Nurse/Unit/Manager (Staff B). An interview was conducted with the Unit Manager (Staff B) at 3:00 p.m. on [DATE]. She said, on [DATE] that she received orders from the physician for a STAT chest X-ray and STAT laboratory tests for a complete blood count (CBC) and a comprehensive metabolic panel (CMP). She said she submitted the requisitions to the mobile X-ray provider for the STAT chest x-ray and to the laboratory for the blood work. She said by the time she left for the evening at approximately 5:15 p.m., neither result for the chest x-ray nor the blood work had been sent to the facility. A review of the Medication Administration Record, [REDACTED]. The Unit Manager (Staff B) said, when she returned the next day, on [DATE], between 8:45 a.m.-9:00 a.m., she saw the lab report on the fax machine. She said she also saw a sheet of paper on the fax machine from the laboratory (Lab) that read something like, Attention: critical please call. She reviewed the laboratory result and noted that the critically high glucose, serum level was 873 ml/dl, the normal range for a serum glucose level was ,[DATE] mg/dl. She said at that time the night shift Registered Nurse (RN), (Staff H) was still working and the day shift Licensed Practical Nurse (LPN), (Staff I) was at the nurse's station. She showed both of them the faxed laboratory report and asked them if either one had seen the abnormal laboratory results. She confirmed that both nurses denied having seen the lab reports. Staff B said, it was at that time that she reported the results to the Director of Nursing (DON). She said she then called the 3:00 p.m. - 11:00 p.m. LPN (Staff J) and asked her if she had seen the laboratory results on her shift. The nurse said at 8:45 p.m. on [DATE], she called the physician to report the abnormal chest X-ray results but she did not see any laboratory reports for this resident before she left at the end of her shift. Staff B said, after she spoke with 3:00 p.m. - 11:00 p.m. LPN (Staff J), she called the laboratory to see if they called the facility to report the critical labs. She said that the laboratory representative said they had called the facility several times with no answer. During the record review, the nurses' progress note read as follows, on [DATE] at 8:45 p.m., X-ray results were in and called into the on call Dr. Orders were given for [MEDICATION NAME]. Dx. Pneumonia. Signed (e-SIGNED) by Staff J (LPN). A nurse's note written on [DATE] at 9:15 a.m. read as follows, alert, verbally unresponsive, [DEVICE] patent feeding given as ordered, no distress noted, resting with eyes closed at long intervals. 8:45 a.m. RHC (respirations have ceased), no heart sounds or pulse palpable. The physician and husband were notified. Signed (e-SIGNED) by the RN (Staff H). On [DATE] at 2:30 p.m., an interview was conducted with the DON. She said, I was told, that Resident #2 had a critical blood glucose level of 873 mg/dl that was done on [DATE] and left on the fax machine until [DATE]. The DON said she spoke with the 3:00 p.m.-11:00 p.m. direct care nurse (Staff J) for Resident #2 on [DATE]. The nurse told the DON that the resident had no increased temperature or respiratory distress on her shift. The nurse said she did an assessment. There was no documentation in the resident record of such assessment that could be found. The DON verified that the nurse did not document the assessment or condition of the resident for the entire 3:00 p.m. - 11:00 p.m. shift on [DATE]. The DON said the nurse was a new nurse. She said the nurse said she did not see the laboratory results on the fax machine during the 3:00 p.m.-11:00 p.m. shift. The DON said the 3:00 p.m. to 11:00 p.m. supervisor checked the fax machine as part of the supervisory tasks but the supervisor was not on duty on [DATE]. She said the nurses were also responsible for checking the fax machine throughout their shifts, especially if there was a STAT laboratory report pending. The DON said, during shift report, the nurses were supposed to inform the on-coming nurse of pending test results, especially if the tests were ordered STAT. The DON said, after the incident was brought to her attention on [DATE], she called the laboratory to see why they did not call the facility on a critical laboratory result no time given. She was told that the laboratory had called, but no one at the facility answered the phone. The DON said she did not follow up with the physician regarding the incident. She said it was the responsibility of the unit manager to call the physician. The DON said she spoke only with the 3:00 p.m. - 11:00 p.m. nurse regarding the process for ordering, obtaining, and reporting laboratory results but she did not complete an education form. She said there was no other in-services/education conducted with all the facility nurses regarding ordering, obtaining, and reporting laboratory result. She said there was no follow-up regarding the failure of the staff to answer the telephone or check the fax machine on a regular basis. She said there was no incident report filed, no investigation completed and no mandated reports to outside agencies filed. On [DATE] at 9:30 a.m., the Nursing Home Administrator (NHA) verified that there were no incident reports found or education provided related to ordering laboratory tests, obtaining results, or reporting results to the physician. She said after the incident, she checked the fax machine and the phone system to ensure that both were in working order. She said the fax machine continued to deliver other documents throughout the evening and night shifts. She said the problems were not related to a mechanical failure for either the phone or the fax machine. She said, There is a receptionist at the front desk until 7:00 p.m. After 7:00 p.m., the phone is switched over to ring at the nurses' stations. The phone and fax machine functioned properly on both shifts. On [DATE] at 11:30 a.m. the Registered Nurse Consultant verified that the facility did not have a policy or a written procedure for ordering laboratory tests, obtaining the results, or notification of critical results to the physician until the in-services were started on [DATE]. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of Professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments a prescribed or authorized by a duly licensed practitioner practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist. On [DATE] at 3:30 p.m., an interview was conducted with the 3:00 p.m. -11:00 p.m. Registered Nurse/Supervisor (Staff F). She said as part of her duties as the supervisor, she checked the fax machine throughout the shift and notified the nurses when laboratory results arrive. She said, in addition, all the nurses were also responsible for checking the fax on a regular basis, especially when they were waiting for STAT laboratory results. On [DATE] at 8:50 a.m., an interview was conducted with Resident #2's Primary Care Physician. He was also the facility's Medical Director. He verified that the facility did not notify him of the resident's blood glucose level until after the resident had expired. He said it was possible that the glucose level was high due to an infection. Based on the STAT chest X-ray results done on [DATE], the resident was diagnosed with [REDACTED]. On [DATE] at 10:30 a.m., an interview was conducted with a representative from the contracted laboratory that was used by the facility. She said, The lab faxed the critical lab results to the facility on [DATE] at 7:40 p.m. An Urgent Fax, with the resident's name and date that showed Urgent Please Call was sent at 7:45 p.m. At 7:46 p.m., the results were faxed again. At 9:15 p.m., the results were faxed manually. At 9:36 p.m., the results were refaxed by the system. She said, after the original fax was sent at 7:40 p.m., the lab called the facility and got no answer so at 7:45 p.m. the Urgent fax was sent. On [DATE] at 12:20 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. Licensed Practical Nurse (Staff I) who was assigned to Resident #2. He said he assisted with after care following her death on [DATE]. He said he was unaware of the abnormal laboratory results until it was brought to his attention. He could not remember who brought it to his attention. He said he received one on one education and possibly a group education related to reporting critical labs to the physician. He was very vague on who gave the education and when it was done. He said he had no education on checking the fax machine for lab results. He said he did not know if anyone was assigned to check the fax machine for labs, mechanical failures, or to make sure the machine had paper. He said if the machine ran out of paper the machine would beep the next time something was sent to the facility to alert the staff to replenish the paper. He said he frequently checked the fax machine throughout his shift and said if he saw a critical lab result on the fax, and it was not related to his resident, he would notify the nurse that was responsible for the resident with the critical labs. The nurse said he checked the fax machine frequently. In his earlier statement he said, he was Unaware of the abnormal laboratory results until it was brought to his attention, which was approximately two hours after the start of his shift at 7:00 a.m. On [DATE] at 3:13 p.m., a telephone interview was conducted with the 3:00 p.m. - 11:00 p.m. LPN (Staff J). She said she knew that someone was supposed to check the fax machine but it was not her. She said, She never checked the fax machine during her shifts. She said she was aware that the resident had STAT laboratory tests pending. She said she flushed the resident's feeding tube between 9:30 p.m. and 10:00 p.m. and the CNA changed the resident around that same time. She said the resident did not show signs or symptoms of distress. Her respirations were even and unlabored. She said the resident opened her eyes as she usually did when her name was called. She verified that she did not do vital signs, temperature and did not fully assess the resident after the increased temperature earlier in the day. She said that Resident #2 was her usual self throughout the shift. The nurse said she reported the abnormal chest X-ray results to the physician but did not see the laboratory results on her shift. On [DATE] at 6:00 p.m., an interview was conducted with the 11:00 p.m.-7:00 a.m. Registered Nurse (Staff H). She said that in the shift report from the 3:00 p.m.-11:00 p.m. nurse she was told that the resident had a chest X-ray that showed pneumonitis and the physician ordered [MEDICATION NAME]. However, she said she was not told, in report, that the resident had STAT labs and the results were pending. She said if she had known, she would have checked the fax machine throughout the night. She said the resident was her usual self throughout the night. She said the resident had even respirations with no coughing or congestion. The nurse said the record review revealed no vital signs were taken after the elevated temperature was documented in the [DATE] nurse's note. The last full set of vital signs, including temperature was documented on [DATE] as blood pressure ,[DATE], temperature 97.2, pulse 78, and respirations 20. These vital signs were all within normal limits. There were no nurse's notes regarding the resident's condition on [DATE] during the 3:00 p.m. - 11:00 p.m. shift. A review of the vital signs history from ,[DATE]-[DATE] indicated that vital signs had not taken from [DATE] - [DATE]. The World Alliance for Patient Safety recently identified poor test follow-up as one of the major processes contributing to unsafe patient care. Failure to follow up test results increases the risk of missed or delayed diagnoses. This may produce suboptimal clinical outcomes (BMJ Quality Safety Health Care. 2011 Feb; 20(2): ,[DATE]). Record review of the Laboratory Service agreement, effective date [DATE], indicated they will provide the facility with results of tests, which include a Comprehensive Metabolic Profile (CMP), as soon as results are released in a timely manner by fax or electronic reporting. Critical results will be reported verbally via the telephone, and followed by a hard copy report. On [DATE] at 10:00 a.m., an interview was conducted with the Nursing Home Administrator. She said that the facility did not have a written policy specifically related to ordering laboratory tests, obtaining the results, and notifying the physician of the results. She said, beginning on the evening of [DATE], no specific time given, the facility started an in- service with all the nurses related to Lab test orders and management. The facility provided supporting documentation of their corrective action plan throughout the survey process from [DATE] - [DATE] to include in-service sign-in sheets for the nurses that received the in-service titled, Lab Test Orders and Management; the handout given to the nurses for the in-service with the step by step process for ordering laboratory tests, obtaining the results, reporting the results to the physician in a timely manner, and a copy of the Laboratory Management Sheet used by the nurses and used as an audit tool. On [DATE], the Register Nurse Consultant (RNC) indicated to the survey team that the NHA and the DON had been relieved of their duties at the facility. An interim NHA and an interim DON had been assigned to the facility. On [DATE] at 2:00 p.m., an interview regarding the facility's corrective action plan was conducted with the Registered Nurse Consultant (RNC), the Interim Director of Nursing and the present Interim Nursing Home Administration. The RNC said that there was a knowledge deficit related to the laboratory log. The nurses were completing the beginning of the log but not completing the following, Results received, MD notified, and new orders received and documented in the progress note. She said it all rolled back to the clinical morning meetings ineffectiveness. If performed correctly missing lab results would be caught in clinical meeting. Some of the nurses were having problems with scheduling laboratory tests in the Electronic Medical Record computer system. They were not scheduling the lab at a specific time, so no one knew when it was due. The RNC stated that she spoke with the laboratory regarding a back-up system. The laboratory was to call and e-mail the Director of Nursing for all critical lab results even if they report the results to the nurse at the facility. The facility will continue to audit the process to verify that all critical labs were obtained and reported to the physician in a timely manner. All labs will be reviewed in the morning meetings and then in stand-down meetings at the end of the shift. The lab monitoring sheet will be reviewed to ensure completeness to include, Resident name, and room number, test ordered, Phlebotomist date and initials, results, MD notification, results on chart, orders received, orders reviewed, and note in chart. Audits will be on going and reviewed in the Quality Assurance meetings until resolved. As of [DATE] at 4:00 p.m., 30 of 33 nurses (91%) had received the training. She said one of the three that had not received the training was no longer employed at the facility, one was on suspension, and one was on an extended sick leave. She said the nurses would not be able to return to work until they completed the in-service. Beginning on [DATE]-[DATE], twenty nurses to include six registered nurses and fourteen licensed practical nurses were interviewed related to their knowledge of ordering laboratory tests, obtaining the results, and reporting critical results to the physician in a timely manner. All those interviewed said they were in-serviced and were able to state and understand the process. During the interviews, seven of fourteen licensed practical nurses said that before the in-services they were unsure of how to use the Laboratory Monitoring Sheet. They said, because of the in-service, they understand why and how to complete the log.

Based on record review and interviews, the facility failed to promptly notify the physician of a critical laboratory result for one (Resident #2) of six residents reviewed for ordering laboratory tests, obtaining the results and reporting critical results to the physician in a timely manner. Findings included: A review of the admission record for Resident #2 indicated that the resident was initially admitted on [DATE] for long-term care. The resident was admitted with [DIAGNOSES REDACTED]. On [DATE], beginning at 11:00 a.m., a record review for Resident #2 revealed the following nurse's progress note, on [DATE] at 2:28 p.m., The Certified Nursing Assistant (CNA) came to the nurse to assess the resident. The resident had a temperature of 101.5 degrees Fahrenheit. The physician's office was called. Awaiting return call. The note was signed (e-SIGNED) by the Registered Nurse/Unit/Manager (Staff B). A review of the Medication Administration Record [REDACTED]. During the record review, the nursing progress note read as follows, on [DATE] at 8:45 p.m., X-ray results were in and called into the on call Dr. Orders were given for [MEDICATION NAME]. Dx. Pneumonia. Signed (e-SIGNED) by Staff J (LPN). A nurse's note written on [DATE] at 9:15 a.m. read as follows, alert, verbally unresponsive, [DEVICE] patent feeding given as ordered, no distress noted, resting with eyes closed at long intervals. 8:45 a.m. RHC (respirations have ceased), no heart sounds or pulse palpable. The physician and husband were notified. Signed (e-SIGNED) by the RN (Staff H). On [DATE] at 2:30 p.m., an interview was conducted with the DON. She said, I was told, that Resident #2 had a critical blood glucose level of 873 mg/dl that was done on [DATE] and left on the fax machine until [DATE]. The DON said she spoke with the 3:00 p.m.-11:00 p.m. direct care nurse (Staff J) for Resident #2 on [DATE]. The nurse told the DON that the resident had no increased temperature or respiratory distress on her shift. The nurse said she did an assessment. There was no documentation in the resident record of such assessment that could be found. The DON verified that the nurse did not document the assessment or condition of the resident for the entire 3:00 p.m. - 11:00 p.m. shift on [DATE]. The DON said the nurse was a new nurse. She said the nurse said she did not see the laboratory results on the fax machine during the 3:00 p.m.-11:00 p.m. shift. The DON said the 3:00 p.m. to 11:00 p.m. supervisor checked the fax machine as part of the supervisory tasks but the supervisor was not on duty on [DATE]. She said the nurses were also responsible for checking the fax machine throughout their shifts, especially if there was a STAT laboratory report pending. The DON said, during shift report, the nurses were supposed to inform the on-coming nurse of pending test results, especially if the tests were ordered STAT. The DON said, after the incident was brought to her attention on [DATE], she called the laboratory to see why they did not call the facility on a critical laboratory result no time given. She was told that the laboratory had called, but no one at the facility answered the phone. The DON said she did not follow up with the physician regarding the incident. She said it was the responsibility of the unit manager to call the physician. The DON said she spoke only with the 3:00 p.m. - 11:00 p.m. nurse regarding the process for ordering, obtaining, and reporting laboratory results but she did not complete an education form. She said there was no other in-services/education conducted with all the facility nurses regarding ordering, obtaining, and reporting laboratory result. She said there was no follow-up regarding the failure of the staff to answer the telephone or check the fax machine on a regular basis. She said there was no incident report filed, no investigation completed and no mandated reports to outside agencies filed. An interview was conducted with the Unit Manager (Staff B) at 3:00 p.m. on [DATE]. She said, on [DATE] she received orders from the physician for a STAT chest X-ray and STAT laboratory tests for a complete blood count (CBC) and a comprehensive metabolic panel (CMP). She said she submitted the requisitions to the mobile X-ray provider for the STAT chest x-ray and to the laboratory for the blood work. She said by the time she left for the evening, at approximately 5:15 p.m., neither result for the chest x-ray nor the blood work had been sent to the facility. She said when she returned the next day, on [DATE], between 8:45 a.m.-9:00 a.m., she saw the lab report on the fax machine. She said she also saw a sheet of paper on the fax machine from the laboratory that read something like, Attention: critical please call. She reviewed the laboratory result and noted that the critically high glucose, serum level was 873 ml/dl. A normal range is ,[DATE] mg/dl. She said at that time the night shift nurse (Staff H, RN) was still working and the day shift nurse (Staff I, LPN) was at the nurse's station. She showed both of them the faxed laboratory report and asked them if either one had seen the abnormal laboratory results. She confirmed that both nurses denied having seen the labs. It was at that time that she reported the results to the Director of Nursing (DON). She said she then called the 3:00 p.m. - 11:00 p.m. nurse (Staff J, LPN) and asked her if she had seen the laboratory results on her shift. The nurse said she called the physician to report the abnormal chest X-ray results, but she did not see any laboratory reports for this resident before she left for the evening. Staff B said after she informed the DON of the incident, she called the laboratory to see if they called the facility to report the critical labs. She said that the laboratory representative said they had called the facility several times with no answer. On [DATE] at 10:30 a.m., an interview was conducted with a representative from the contracted laboratory that was used by the facility. She said, The lab faxed the critical lab results to the facility on [DATE] at 7:40 p.m. An Urgent Fax, with the resident's name and date that showed Urgent Please Call was sent at 7:45 p.m. At 7:46 p.m., the results were faxed again. At 9:15 p.m., the results were faxed manually. At 9:36 p.m., the results were refaxed by the system. She said, after the original fax was sent at 7:40 p.m., the lab called the facility and got no answer so at 7:45 p.m. the Urgent fax was sent. On [DATE] at 3:30 p.m., an interview was conducted with the 3:00 p.m. -11:00 p.m. Registered Nurse/Supervisor (Staff F). She said as part of her duties as the supervisor, she checked the fax machine throughout the shift and notified the nurses when laboratory results arrive. She said, in addition, all the nurses were also responsible for checking the fax on a regular basis, especially when they were waiting for STAT laboratory results. On [DATE] at 9:30 a.m., the Nursing Home Administrator (NHA), said after the incident, she checked the fax machine and the phone system to ensure that both were in working order. She said the fax machine continued to delivery other documents throughout the evening and night shifts. She said the problems were not related to a mechanical failure for either the phone or the fax machine. She said there is a receptionist at the front desk until 7:00 p.m. After 7:00 p.m., the phone is switched over to ring at the nurses' stations. The phone and fax machine functioned properly on both shifts. On [DATE] at 12:20 p.m., an interview was conducted with the 7:00 a.m. - 3:00 p.m. LPN (Staff I) who was assigned to Resident #2. He said he assisted with after care following her death on [DATE]. He said he was unaware of the abnormal laboratory results until it was brought to his attention. He could not remember who brought it to his attention. He said he received one on one education and possibly a group education related to reporting critical labs to the physician. He was very vague on who gave the education and when it was done. He said he had no education on checking the fax machine for lab results. He said he did not know if anyone was assigned to check the fax machine for labs, mechanical failures, or to make sure the machine had paper. He said if the machine ran out of paper the machine would beep the next time something was sent to the facility to alert the staff to replenish the paper. He said he frequently checked the fax machine throughout his shift and said if he saw a critical lab result on the fax, and it was not related to his resident, he would notify the nurse that was responsible for the resident with the critical labs. The nurse said he checked the fax machine frequently. In his earlier statement he said, he was Unaware of the abnormal laboratory results until it was brought to his attention, which was approximately two hours after the start of his shift at 7:00 a.m. On [DATE] at 3:13 p.m., a telephone interview was conducted with the 3:00 p.m. - 11:00 p.m. LPN (Staff J). She said she knew that someone was supposed to check the fax machine but it was not her. She said, She never checked the fax machine during her shifts. She said she was aware that the resident had STAT laboratory tests pending. She said she flushed the resident's feeding tube between 9:30 p.m. and 10:00 p.m. and the CNA changed the resident around that same time. She said the resident did not show signs or symptoms of distress. Her respirations were even and unlabored. She said the resident opened her eyes as she usually did when her name was called. She verified that she did not do vital signs, temperature and did not fully assess the resident after the increased temperature earlier in the day. She said that Resident #2 was her usual self throughout the shift. The nurse said she reported the abnormal chest X-ray results to the physician but did not see the laboratory results on her shift. On [DATE] at 6:00 p.m., an interview was conducted with the 11:00 p.m.-7:00 a.m. Registered Nurse (Staff H). She said that in the shift report from the 3:00 p.m.-11:00 p.m. nurse she was told that the resident had a chest X-ray that showed pneumonitis and the physician ordered [MEDICATION NAME]. However, she said she was not told, in report, that the resident had STAT labs and the results were pending. She said if she had known, she would have checked the fax machine throughout the night. She said the resident was her usual self throughout the night. She said the resident had even respirations with no coughing or congestion. The nurse said the record review revealed no vital signs were taken after the elevated temperature was documented in the [DATE] nurse's note. The last full set of vital signs, including temperature was documented on [DATE] as blood pressure ,[DATE], temperature 97.2, pulse 78, and respirations 20. These vital signs were all within normal limits. There were no nurse's notes regarding the resident's condition on [DATE] during the 3:00 p.m. - 11:00 p.m. shift. On [DATE] at 8:50 a.m., an interview was conducted with Resident #2's Primary Care Physician. He was also the facility's Medical Director. He verified that the facility did not notify him of the resident's blood glucose level until after the resident had expired. He said it was possible that the glucose level was high due to an infection. Based on the STAT chest X-ray results done on [DATE], the resident was diagnosed with [REDACTED]. On [DATE] at 10:00 a.m., an interview was conducted with the Nursing Home Administrator. She said that the facility did not have a written policy specifically related to ordering laboratory tests, obtaining the results, and notifying the physician of the results. She said, beginning on the evening of [DATE], no specific time given, the facility started an in- service with all the nurses related to Lab test orders and management. On [DATE] at 11:30 a.m. the Registered Nurse Consultant verified that the facility did not have a policy or a written procedure for ordering laboratory tests, obtaining the results, or notification of critical results to the physician until the in-services were started on [DATE]. The Florida Nurse Practice Act, Chapter 464.003 defines the practice of Professional nursing as the performance of those acts requiring substantial specialized knowledge, judgment, and nursing skill based upon applied principles of psychological, biological, physical, and social sciences which shall include, but not be limited to: the administrations of medications and treatments a prescribed or authorized by a duly licensed practitioner practice of practical nursing as the performance of selected acts, including the administration of treatments and medications, in the care of the ill, injured, or informed and the promotion of wellness, maintenance of health, and prevention of illness of others under the direction of a registered nurse, a licensed physician, a licensed osteopathic physician, a licensed podiatric physician, or a licensed dentist.